tag:blogger.com,1999:blog-31308752988937559062017-09-18T15:27:27.384-07:00Evidence-Based MommyCombining the art of parenting with cold, hard science.EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.comBlogger39125tag:blogger.com,1999:blog-3130875298893755906.post-55428362783729423462012-03-08T21:38:00.001-08:002012-03-08T23:22:29.643-08:00It's All Fun and Games, Until Someone Loses...<div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-9ahqG44QDws/T1mUjm8JzPI/AAAAAAAAHMg/_pWJEA_z90I/s1600/JJBlackEye.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="http://4.bp.blogspot.com/-9ahqG44QDws/T1mUjm8JzPI/AAAAAAAAHMg/_pWJEA_z90I/s320/JJBlackEye.jpg" width="240" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;">My husband did that to our son. &nbsp;Before you call CPS, allow me to explain: JJ was hit in the eye by his dad's fly ball. &nbsp;Fortunately, he didn't suffer a serious injury, and by the next day, he was proudly showing off his shiner at school.</span><br /><div><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div><div><span style="font-family: Arial,Helvetica,sans-serif;">With opening day approaching and JJ now playing AAA ball, I'm getting more nervous than a mole in a Chuck-E-Cheese arcade. (I'm the kind of gal who ducks when a <i>frisbee </i>is thrown at her). &nbsp;Those balls are being thrown faster and wilder, now that it's 100% kid pitch. &nbsp;My one consolation is that he's not playing football. &nbsp;In fact, baseball has one of the lowest rates of injury among youth sports. &nbsp;The problem is that it has the <a href="http://www.ncbi.nlm.nih.gov/pubmed/19030141">highest rates of facial injuries</a>, including fractures and eye and dental injuries.</span></div><div><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div><div><span style="font-family: Arial,Helvetica,sans-serif;">This is <a href="http://www.ncbi.nlm.nih.gov/pubmed/21303178">what happens to an eyeball</a> when it's struck head-on by a 66-mph ball:</span></div><div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-1rnw7Qa684g/T1mUEGu3IsI/AAAAAAAAHMY/29xg4l6pbr8/s1600/EyeImpactBaseball.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="195" src="http://2.bp.blogspot.com/-1rnw7Qa684g/T1mUEGu3IsI/AAAAAAAAHMY/29xg4l6pbr8/s200/EyeImpactBaseball.jpg" width="200" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div><div><span style="font-family: Arial,Helvetica,sans-serif;">Most kids my son's age can't pitch faster than 50 mph, but 66 mph is well within the range of 13-and 14-year-old pitchers. &nbsp;While this degree of deformation rarely leads to globe rupture (think of a squished grape), it can cause retinal detachment and vision loss.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">There are two ways to reduce the risk of baseball facial injuries: safety balls and faceguards. &nbsp;Safety balls include the reduced-impact balls, which contain a polyurethane core instead of yarn wrapped around cork. &nbsp;There haven't been any randomized, controlled trials of this preventive equipment. &nbsp;In fact, one group of researchers approached a youth league in Indiana about performing an RCT of faceguards, but the league "refused to cooperate," so &nbsp;they ran a <a href="http://www.ncbi.nlm.nih.gov/pubmed/11003192">nonrandomized study</a>&nbsp;instead. &nbsp;The 136 coaches who chose to make faceguards mandatory reported fewer facial impacts or injuries (12.3%) than the 102 who made them voluntary (15.7%). &nbsp;Most of these injuries were minor, as only 10 children (8 of whom were on the control teams) sought medical treatment.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">USA Baseball commissioned a more rigorous <a href="http://jama.ama-assn.org/content/289/5/568.abstract">observational study</a> looking at the rates of ball--related injuries and the effectiveness of safety balls and faceguards. &nbsp;The authors used the data on injuries compensated by Little League's insurance for their calculations, so by design, these were more serious injuries. The overall risk of ball-related injury resulting in compensation was extremely low -- 28 per 100,000 players per season. &nbsp;As expected, the risk of injury increased with the level of competition, while the use of safety balls and faceguards decreased. &nbsp;After adjustment for level of competition, safety balls were found to decrease the rate of injury by 23%, and faceguards by 35%.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Despite this data, safety balls and faceguards aren't mandated by most youth leagues. &nbsp;Safety balls just don't bounce like hardballs, and the most common argument against faceguards is the reduction in visibility. &nbsp;<i>Recommending </i>faceguards won't significantly increase their use; leagues would have to mandate them, to level the playing field. &nbsp;I would love to see a randomized, controlled trial of faceguards, not for safety reasons, but to see whether they affect one's batting average. &nbsp;For younger kids, faceguards may have the advantage of reducing their fear of the ball, and possibly increasing their chances of hitting it. &nbsp;As a team photographer, I have too many shots to count of 6-year-olds swinging with their eyes shut.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">The last argument against faceguards is purely from a numbers perspective. &nbsp;With an injury rate of only 28 per 100,000, and a 35% reduction in risk, you would have to add faceguards to 5,714 helmets to prevent one injury. &nbsp;It would be helpful to know if leagues that require safety balls and faceguards pay less in insurance premiums than those that don't. &nbsp;And it sure would be nice if insurance companies would cut them a break for making the safety of their players paramount.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-12450618768059744372012-02-10T20:38:00.000-08:002012-02-10T20:38:26.960-08:00When the Zebra is a Horse<div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-uU1u0XHm-ts/TzWjbaul7cI/AAAAAAAAHEc/Up0X35abUcE/s1600/Zorse.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="269px" sda="true" src="http://3.bp.blogspot.com/-uU1u0XHm-ts/TzWjbaul7cI/AAAAAAAAHEc/Up0X35abUcE/s320/Zorse.jpg" width="320px" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">Is this a zebra, a horse, or a Photoshop disaster?*</span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Here's a trivia question for the doctor-folks who follow my blog:&nbsp; What's the most common cause of encephalitis of uncertain etiology in children and young adults?&nbsp; Hint: It's not herpes, rabies or even West Nile.</span><br /><br /><span style="font-family: Arial;">It's anti-NMDA receptor encephalitis.</span><br /><br /><span style="font-family: Arial;">If you already know what I'm talking about, I'm impressed.&nbsp; I had never heard of this entity until today, when our chair forwarded everyone in the medicine department a <a href="http://cid.oxfordjournals.org/content/early/2012/01/19/cid.cir1038.full">report</a> from the California Encephalitis Project (CEP).&nbsp; In fact, anti-NMDAR wasn't even discovered until 2007.</span><br /><br /><span style="font-family: Arial;">Encephalitis is inflammation of the brain, resulting in fever, confusion, seizures and sometimes permanent neurologic damage and death.&nbsp; It's usually caused by viruses and sometimes bacteria, when it accompanies meningitis.&nbsp; Anti-NMDAR is not an infection, however.&nbsp; NMDA is a ubiquitous neurotransmitter, and in this disease, the body produces antibodies that attack the NMDA receptor, leading to gross neurological dysfunction.&nbsp; </span><br /><br /><span style="font-family: Arial;">Anti-NMDAR can be a devastating illness.&nbsp; It presents with hallucinations, language problems and vital sign instability, among other signs and symptoms.&nbsp; In the CEP report, 40% of patients required life support for respiratory failure.&nbsp; Fortunately, there is effective treatment for anti-NMDAR.&nbsp; The majority respond to a potent cocktail of immune suppression -- the exact opposite of how you would normally treat infectious encephalitis.</span><br /><br /><span style="font-family: Arial;">And here's the surprising part of the report:&nbsp; Out of 761 cases of encephalitis reported over the 3 to 4 year period, 47 were tested for NMDAR because of clinical suspicion.&nbsp; Thirty-two, or 68%, tested positive.&nbsp; In fact, even though only a fraction of cases were tested for anti-NMDAR, it was the most common cause of encephalitis in this case series.&nbsp; Two-thirds of cases were in children.</span><br /><br /><span style="font-family: Arial;">Now encephalitis is still a very rare illness, with an incidence rate of 1 out of 200,000 in the U.S., so even if anti-NMDAR is a common cause&nbsp;of encephalitis, it's still&nbsp;an extremely uncommon disease.&nbsp; (Please do <i>not</i> charge into your pediatrician's office demanding to have little Johnny tested because he has a fever or is&nbsp;moodier than usual.)&nbsp; The CEP only collected cases of encephalitis of unknown etiology, so many of the diagnosed&nbsp;viral cases&nbsp;were excluded from this analysis, artificially inflating the relative frequency of anti-NMDAR.&nbsp; On the other hand, because so few doctors are aware of this disease, we are probably undertesting and missing cases.</span><br /><br /><span style="font-family: Arial;">In medicine, we have a&nbsp;saying:&nbsp; When you hear hoofbeats, think of horses, not zebras.&nbsp; In other words, don't go on an expensive hunt for a rare disease unless you have a compelling reason to do so.&nbsp;&nbsp;When it comes to&nbsp;childhood encephalitis,&nbsp;though, anti-NMDAR may turn out to be the proverbial horse.</span><br /><br /><span style="font-family: Arial; font-size: x-small;">*It's a zorse (zebra-horse hybrid).</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com6tag:blogger.com,1999:blog-3130875298893755906.post-1677331008761285742012-02-08T17:44:00.000-08:002012-02-09T09:38:51.589-08:00It's Not Easy Eating Green<span style="font-family: Arial;">A reader sent me a recent <a href="http://www.cam.ac.uk/research/discussion/a-spoonful-of-sugar-or-a-bitter-blocker/">article</a> about methods used throughout history to get children to take their medicines.&nbsp; While the piece focused on sweet talk and sweeteners, the biogeek in me was drawn to a comment about a new compound, GIV3616, that blocks the bitter taste receptors on the tongue.&nbsp; A <a href="http://portal.acs.org/portal/acs/corg/content?_nfpb=true&amp;_pageLabel=PP_ARTICLEMAIN&amp;node_id=222&amp;content_id=CNBP_026938&amp;use_sec=true&amp;sec_url_var=region1&amp;__uuid=d09834a3-c89b-43b6-810a-8396b8a6ff83">scientist from Givaudan Flavors</a>, developer of this chemical, noted that for veggie-phobic children, </span><span style="font-family: Arial,Helvetica,sans-serif;">"We’d like to be able to make their diets more enjoyable by masking the off-putting flavors of bitterness. Blocking these flavors we call off-notes could help consumers eat healthier and more varied diets."&nbsp; I was dying to get a hold of this bitter blocker to sprinkle on my <a href="http://www.evidencebasedmommy.blogspot.com/2011/11/ketchup-counts.html">picky daughter's</a> kale, but&nbsp;that would probably alienate those of you who eschew genetically modified, irradiated, non-organic, non-sustainable, non-locally produced&nbsp;Frankenfoods.&nbsp; Besides, when I did a Google Scholar search on this compound, nothing&nbsp;has been published -- not even animal safety studies.&nbsp; (I'm sure it's&nbsp;proprietary.)</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">It turns out there's a cheaper, low tech solution to increasing vegetable consumption in kids.&nbsp; This week in <i>JAMA</i>, a psychologist, an economist, a&nbsp;marketing professor&nbsp;and two nutritionists <strike>walk into a bar</strike> published a <a href="http://jama.ama-assn.org/content/early/2012/01/31/jama.2012.170.extract">study</a> in which they placed photographs of vegetables in elementary school lunch tray compartments.&nbsp; They measured vegetable consumption&nbsp;on a day when the trays had the photographs and compared it to a day when they didn't have the photographs.&nbsp; These valiant researchers&nbsp;(or more likely, their undergraduate assistant in charge of "data acquisition") went so far as to scrape off and weigh uneaten vegetables left on the trays, tables and floors.</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-rLpYxryWHjo/TzK5xa6ri2I/AAAAAAAAHEM/Gwv9hv6TMcc/s1600/VeggieTray.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="185px" sda="true" src="http://1.bp.blogspot.com/-rLpYxryWHjo/TzK5xa6ri2I/AAAAAAAAHEM/Gwv9hv6TMcc/s320/VeggieTray.jpg" width="320px" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">Does your kid's lunch tray look like this....</span></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-EV2U6X5F3A8/TzK6G9oVYCI/AAAAAAAAHEU/Ds_N61MVhgM/s1600/LunchTray.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240px" sda="true" src="http://1.bp.blogspot.com/-EV2U6X5F3A8/TzK6G9oVYCI/AAAAAAAAHEU/Ds_N61MVhgM/s320/LunchTray.jpg" width="320px" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">...or this?</span></div><br /><span style="font-family: Arial;">So what did they find?&nbsp; On the positive side, the percentage of children scooping green beans and carrots into those compartments went up from 6-12% to 15-37%, and overall consumption increased modestly.&nbsp; On the downside, a lot of the kids left their veggies uneaten (in fact, more carrots were wasted in the photograph group), and even with the overall increase, consumption still did not meet government recommendations.&nbsp; The study was also performed over a mere two days.&nbsp; Kids will figure out in no time that no one's going to punish them if they scoop pudding into a green bean compartment.</span><br /><br /><span style="font-family: Arial;">As for me, I'll keep waiting for that magic bullet.&nbsp;&nbsp;To the marketing geniuses at Givaudan:&nbsp; hurry up, rechristen your license-plate chemical "Flavia," and release it to the general public.&nbsp;And&nbsp; one more favor, if you please: Publish a study showing your bitter blocker won't make my daughter grow a third eyeball.*</span><br /><br /><span style="font-family: Arial; font-size: x-small;">*What's more likely is that she would grow more bitter taste receptors in response to chronic blockade.&nbsp; (That's the mechanism by which people become tolerant to narcotics or alcohol).&nbsp; If she were to suddenly stop using the chemical, she would be more sensitive to bitterness than ever before.</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com4tag:blogger.com,1999:blog-3130875298893755906.post-35484833737596939892012-01-26T22:13:00.000-08:002012-01-26T22:13:44.281-08:00Talking to Your Girls: The Best Vaccine of All<div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-5krJfuMh7k4/TyI4W5P4FZI/AAAAAAAAHEE/AiGB8wCeXdQ/s1600/HPVVaccine.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-5krJfuMh7k4/TyI4W5P4FZI/AAAAAAAAHEE/AiGB8wCeXdQ/s1600/HPVVaccine.jpg" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">In a previous <a href="http://www.ncbi.nlm.nih.gov/pubmed/17151031">posting</a>, I noted that there are almost no studies looking at whether giving the human papillomavirus (HPV) vaccine to adolescents increases unsafe sexual behavior -- what some call a passport to promiscuity for girls and a license to drill for boys.&nbsp; Although there are still no studies looking at behavior post-vaccine, the <i>Archives of Pediatric and Adolescent Medicine</i> just published a <a href="http://archpedi.ama-assn.org/cgi/content/abstract/166/1/82">study</a> on the attitudes and beliefs of girls who got the HPV shot.</span><br /><span style="font-family: Arial;">The authors asked the girls (ages 13-21) to agree or disagree with statements like, "After getting the shot against HPV, I am less worried about getting a sexually transmitted disease other than HPV," and "After getting the shot against HPV, I think that condom use (or having fewer sexual partners) is less necessary."</span><br /><br /><span style="font-family: Arial;">First, the good news:&nbsp; Only 4% of the girls felt less of a&nbsp;need to practice safe sex because of the vaccine.&nbsp; The investigators then looked at what factors were associated with this belief.&nbsp; Some risk factors were predictable, but a few were surprising.&nbsp; A lower perceived need for safe sex was associated with:</span><br /><ul><li><span style="font-family: Arial;">Lower knowledge about HPV and the vaccine</span></li><li><span style="font-family: Arial;">Lack of condom use at last intercourse</span></li><li><span style="font-family: Arial;">Lack of maternal communication about the HPV vaccine</span></li><li><span style="font-family: Arial;"><i>Teacher or physician serving as the source of HPV vaccination information</i></span></li></ul><span style="font-family: Arial;">The last one threw me for a loop.&nbsp; Surely the most reliable information about the vaccine and STDs comes from doctors and sex education teachers?&nbsp; The problem is that even if they are dispensing appropriate advice (which may or may not be a correct assumption) , they may not be doing so in a way that's understandable to teens and their mothers.&nbsp; On the flip side, it looks like moms can have a positive impact in their daughters' behavior, particularly if they talk to them about the limitations of the vaccine, including its lack of protection against some HPV strains, other STDs and pregnancy.</span><br /><br /><span style="font-family: Arial;">Though very few girls agreed that the vaccine would allow them to have more unprotected sex, survey answers don't necessarily predict behavior.&nbsp; Even before the vaccine, over half of the adolescents in this clinic were sexually experienced, and most were not using condoms reliably.&nbsp; It's doubtful that the vaccine will <i>decrease</i> the rate of unsafe sexual practices, unless it's accompanied with appropriate counseling.</span><br /><br /><span style="font-family: Arial;">So does this mean we shouldn't be vaccinating our daughters against, because of the theoretical increased risk of unsafe behavior?&nbsp; Of course not.&nbsp; The advent of effective antiretroviral therapy for HIV in the late 1990's was accompanied by an <a href="http://www.ncbi.nlm.nih.gov/pubmed/17151031">increase in the rate of unprotected sex, and subsequent gonorrhea and syphilis epidemics</a>, in gay and bisexual men.*&nbsp; Yet it would be completely unethical to withhold effective drug therapy because of its unintended behavioral consequences.&nbsp; No, it simply means that doctors and, more importantly, parents have our work cut out for us when it comes to educating our kids.</span><br /><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*Despite the increases in other STDs in the San Francisco Bay Area, there was no increase in the HIV incidence in gay men during this time period.&nbsp; The theory is that HIV-positive men had unsafe sex only with HIV-positive men, and HIV-negative only with HIV-negative.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-74097578322401933232012-01-17T21:45:00.000-08:002012-01-18T09:45:52.971-08:00Does Being a Mom = Letting Yourself Go?<span style="font-family: Arial,Helvetica,sans-serif;">I missed my 20th college reunion, having given birth just 6 weeks prior.&nbsp; I wasn't worried about travelling with a newborn.&nbsp; I just didn't want to chance a meeting with any old exes, while I was looking puffy, poochy and sleep-deprived.&nbsp;(On the plus side, I was rather buxom).&nbsp;Afterwards, I&nbsp;prevailed upon a&nbsp;friend to dish on all our old classmates.&nbsp; As he ran the "hot or not" list, I noticed that the former was comprised mostly of his single, childless pals, while the latter was made up of couples with kids.&nbsp; It wasn't an entirely fair comparison, as my friend is gay, and he and his buddies start with a level of fabulousness lacking in us breeders.&nbsp; But is it a given that having children will make you look older, fatter and less attractive?</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-C7VXvvXQtis/TxZZLT63LUI/AAAAAAAAHDw/woD_gR8x_6o/s1600/BeforeAfterKids.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="199px" src="http://2.bp.blogspot.com/-C7VXvvXQtis/TxZZLT63LUI/AAAAAAAAHDw/woD_gR8x_6o/s320/BeforeAfterKids.jpg" width="320px" /></a></div><div style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">This is what having 2.5 kids does to you.</span></span>*</div><br /><span style="font-family: Arial;">Let's start with the easiest question to answer:&nbsp; Do children make you fat?&nbsp; In a word, yes.&nbsp; Numerous studies have shown that mothers have a higher body mass index (BMI) than non-mothers.&nbsp; Those pregnancy pounds don't just convert into postpartum pounds; they translate into post-post-postpartum pounds.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/15530586">study</a> looking at 2,000 women over 65 years of age found that the risk of obesity increased 7% with each live birth.&nbsp; Polishing off those half-eating chicken nugget meals </span><span style="font-family: Arial;">obviously takes its toll, not to mention the lack of exercise.&nbsp; Several studies have found that physical inactivity increases with the onset of parenthood.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/16262541">study</a> in over 8,000 young women found that when someone becomes a mother, her risk of physical inactivity rises from about 40% to 60%.&nbsp; Although moms bear the brunt of the weight burden, dads aren't exempt from the curse:&nbsp; Men also have a <a href="http://www.ncbi.nlm.nih.gov/pubmed/15006281">4% increased risk in obesity with each additional child</a>.</span><br /><br /><span style="font-family: Arial;">What about looking older?&nbsp; Before&nbsp;my first son&nbsp;was born, I had a grand total of three white hairs; within a year, I was spending 20 minutes a day plucking them.&nbsp; Nine years later, I've stopped, with the fervent hope that my bald spots will recover.&nbsp; I couldn't find any studies on whether parenting causes premature greying.&nbsp; While acute, severe stress can cause diffuse hair loss, there's no evidence that chronic, low-lying stress induces baldness.&nbsp; What about wrinkles, or other facial signs of aging?</span><br /><br /><span style="font-family: Arial;">One&nbsp;well-designed <a href="http://www.ncbi.nlm.nih.gov/pubmed/16407433">study</a> looked at&nbsp;the effect of environmental factors, including parenthood,&nbsp;on perceived age.&nbsp; Nurses were asked to estimate the age of over 1,800 elderly twins based on facial photographs.&nbsp; I was relieved to discover that the number of children did not affect perceived age.&nbsp; </span><span style="font-family: Arial;">Then again, all of these twins were at least 70 years old, so maybe other, stronger environmental factors, such as smoking and sun exposure, obliterated any small effect fecundity might have had on appearance.&nbsp; (One silver lining, for those of us still working off that baby bump:&nbsp; thin people in this study looked older than chunky ones.)</span><br /><br /><span style="font-family: Arial;">A similar <a href="http://www.ncbi.nlm.nih.gov/pubmed/21179450">study</a> was performed in Shanghai in 250 women, aged 25 to 70 years.&nbsp; The researchers didn't look specifically at whether the number of children affected one's perceived age, presumably because of China's one-child policy.&nbsp; However, they did find that&nbsp;having more than 3 members in your household made you look, on average, 2 years older.&nbsp; Whether this was due to the stress of having that extra, illicit child, or more likely, an aging parent or in-law in the home,&nbsp;wasn't clear, but it might be a good reason to push your kids out of the nest when they turn 18.</span><br /><br /><span style="font-family: Arial;">Finally, for those of you with babies or young children, don't underestimate the benefit of a good night's sleep.&nbsp; The research on beauty sleep is scant, but leave it to the Swedes to publish the one controlled <a href="http://www.ncbi.nlm.nih.gov/pubmed/21156746">study</a> on this topic.&nbsp; Twenty-three young adults were photographed after 8 hours of normal sleep, and again after a night of only 5 hours of sleep.&nbsp; The photographs were then rated by observers blinded to the intervention.&nbsp; Sleep deprivation reduced attractiveness by about 4% and perceived health by about 6%.&nbsp; </span><br /><br /><span style="font-family: Arial;">Despite the meager evidence,&nbsp;I'm convinced that having kids makes you look frumpier, but the trade-off is worth it.&nbsp; My advice is simply to put on some make-up, lose the mommy jeans, eat healthier, exercise more, get eight hours of sleep every night....</span><br /><br /><span style="font-family: Arial;">Oh, forget it.&nbsp; Just call the plastic surgeon and be done with it already.</span><br /><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*Actually, this photo came from Faces of Meth.&nbsp; But who's to say she didn't have a baby in the intervening years? </span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-89677118913224436312012-01-10T17:00:00.000-08:002012-01-10T17:00:53.391-08:00Catching Your Death of Cold<span style="font-family: Arial,Helvetica,sans-serif;">Growing up, many of us were admonished by our moms to wear our coats, or we'd "catch our death of cold."&nbsp; Chinese grandmas have a particular fondness for bundling kids&nbsp;so tightly that&nbsp;they're splinting their joints.&nbsp; We know now, of course, that being cold doesn't cause colds; viruses do.&nbsp;</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-zmv5jZrSR_w/TwzfFSl6FFI/AAAAAAAAG_s/d29zYkkjEd4/s1600/BundledBabies.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="212" src="http://4.bp.blogspot.com/-zmv5jZrSR_w/TwzfFSl6FFI/AAAAAAAAG_s/d29zYkkjEd4/s320/BundledBabies.jpg" width="320" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">But like many things in science, the evidence isn't as clear-cut as you might think.&nbsp; Multiple studies have found a strong link between outdoor temperature, as well as low humidity, and the risk of respiratory infections.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/18977127">study</a>, for instance, found a 4% increase in upper respiratory infections with every 1 C decrease in temperature.&nbsp; Influenza shows strong seasonality in temperate regions, with peak infection rates in winter, but none in tropical areas.&nbsp; Of course, this doesn't prove cause and effect.&nbsp; </span><span style="font-family: Arial,Helvetica,sans-serif;">The conventional wisdom is that colds and the flu are more common in winter because of an increase in indoor crowding.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">There is another possible explanation for this phenomenon.&nbsp; Our first line of defense against respiratory viruses is that cozy mucus blanket lining our noses.&nbsp; Microscopic hairs sweep the germ-laden mucus towards the back of the throat, where it's swallowed and sterilized by stomach acid.&nbsp; "Nasal mucus velocity" drops significantly in cold weather, preventing viral clearance.&nbsp; (Sounds like one of the less popular <i>Magic School Bus</i> episodes.)&nbsp; Cold also impairs the function of macrophages, white blood cells that ingest germs.&nbsp; Finally, many respiratory viruses replicate best at lower temperatures.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/17953482">Guinea pig studies</a> do confirm an increased risk of transmission of the flu in cold, low humidity lab conditions.*&nbsp;</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-eiTQoHUMvbA/TwvgMi5euzI/AAAAAAAAG_c/nH3mEQWEelk/s1600/GuineaPigSnuggie.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="188px" src="http://3.bp.blogspot.com/-eiTQoHUMvbA/TwvgMi5euzI/AAAAAAAAG_c/nH3mEQWEelk/s320/GuineaPigSnuggie.jpg" width="320px" /></a></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">However, there are no studies on the protective </span></span></div><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">properties of the Snuggie, in guinea pigs or humans.</span></span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">While there are no human trials on the direct effects of low temperature on influenza infection, controlled studies exist for the common cold.&nbsp; In one 1968 <a href="http://www.nejm.org/doi/full/10.1056/NEJM196810032791404">study</a>, forty-nine "volunteers" from the Texas State Department of Corrections were nasally inoculated with "virus-containing fluids" collected from sick Marines.&nbsp; Half were then subjected to cold conditions, involving, among other things, sitting in a 4 C (39 F) room in shorts and undershirts for a couple of hours.&nbsp; The two groups showed no difference in the rates of rhinovirus shedding or cold symptoms, and you can bet this study had 100% follow-up.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Another <a href="http://www.ncbi.nlm.nih.gov/pubmed/8151855">study</a> took the opposite approach, looking at the effects of hot, humidified air in university students who were also experimentally infected with rhinovirus.&nbsp; This time, the subjects were comfortably ensconced in private hotel rooms and administered either placebo vapor or warm steam.&nbsp; There was no difference in the primary outcome of viral shedding.&nbsp; Another <a href="http://www.ncbi.nlm.nih.gov/pubmed/2500196">randomized, double-blind trial</a> found a reduction in cold symptoms with hot, humidified air, but again, no decrease in viral shedding.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Case closed, right?&nbsp; Believe or not, research in this area continues, almost 2,000 years after the Greek physician Galen wrote about the four humors ("phlegmatic" being the "cold and moist" humor).&nbsp; The latest was a <a href="http://www.ncbi.nlm.nih.gov/pubmed/16286463">study</a> published by the Common Cold Centre in the UK, which randomized180 volunteers to place their feet in cold water or an empty bowl for 20 minutes.&nbsp; </span><span style="font-family: Arial,Helvetica,sans-serif;">Why did the investigators decide to chill feet instead of noses?&nbsp; Their rationale was that chilling of the body surface decreases the temperature of mucosal surfaces, via reflex constriction of the blood vessels in the nose.&nbsp;</span><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp; Over the next five days, significantly more of the chilled subjects developed cold symptoms than&nbsp;the control group - 29% vs. 9%.&nbsp; Despite the relatively large sample size and achievement of "statistical significance," this study sounds like an grade school science project, and not a winning one at that.&nbsp; The subjects were aware of the hypothesis of the study -- that chilling might affect the development of cold symptoms -- so the nocebo effect may have been in play.**&nbsp; None of the volunteers underwent viral cultures to confirm infection.&nbsp; And it's hard to believe a mere 20-minute foot dip could triple your chances of getting sick.&nbsp; So is bundling up really going to protect you from infection?&nbsp; Probably not.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Then again, would it kill you to listen to your mother?</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">*Guinea pigs were discovered in 2006 to be an excellent experimental model for the flu.&nbsp; I have no idea why it took so long figure this out, when guinea pigs have been, well, guinea pigs since time immemorial.</span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">**A nocebo is the opposite of a placebo: something that makes you feel worse, though it has no actual, independent effect. </span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-8182023771980472442012-01-03T21:45:00.000-08:002012-01-04T17:43:15.568-08:00Game On!<span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">My husband and I caved in and bought handheld Nintendoes for our kids this Christmas.&nbsp; (Thank you, Craigslist!) Though we usually set a 15-minute limit on schooldays, we let our kids play as much as they wanted over the holidays.&nbsp; </span></span><span style="font-family: Arial;">When I couldn't stand the peace and quiet anymore, I shooed them out of the house for a little sunshine and exercise.&nbsp; I quickly learned the downside of handheld gaming devices:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-CHCpzbx0PMw/TwPmS30Ia-I/AAAAAAAAG_M/H3VzX9jWqTo/s1600/NintendoSwing.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-CHCpzbx0PMw/TwPmS30Ia-I/AAAAAAAAG_M/H3VzX9jWqTo/s320/NintendoSwing.jpg" width="232" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">So did those hours of nonstop gaming irreversibly damage our children's vulnerable brains?&nbsp; Don't worry, I won't rehash the numerous studies linking video games with <a href="http://www.ncbi.nlm.nih.gov/pubmed/20192553">aggression</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20603258">attention problems</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21146676">obesity</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21463355">depression and suicidality</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=video%20game%20ownership%20academic">poor academic performance</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/9621722">addiction</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/17385999">reckless driving</a>,&nbsp;<a href="http://www.ncbi.nlm.nih.gov/pubmed/20637224">smoking, alcohol and drug use</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22069461">hypertension and high cholesterol</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22099236">inadequate sleep</a>, <a href="http://pediatrics.aappublications.org/content/93/4/551.short">seizures</a>,&nbsp;<a href="http://www.ncbi.nlm.nih.gov/pubmed/15119012">pulmonary embolism*</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=wii%20ruptured%20globe">ruptured eyeballs</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=wii%20hemothorax">internal bleeding**</a>, five out of the seven deadly sins (<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=video%20games%20materialism">greed</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22007010">sloth</a>, <a href="http://www.ncbi.nlm.nih.gov/pubmed/21490141">gluttony</a>, <a href="http://www.tandfonline.com/doi/abs/10.1080/15213260802491986">lust</a>, <a href="http://www.rovio.com/en/our-work/games/view/1/angry-birds">avian anger</a>) and the <a href="http://en.wikipedia.org/wiki/Grand_theft_auto_iv">decline of Western civilization</a>.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Because that could get really tedious.</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"></span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Let's focus instead on the benefits of video games.&nbsp; As you know, I'm the master of finding evidence&nbsp;to back up&nbsp;how I would parent</span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"> anyway.&nbsp; And just to make it a little more challenging, I'm excluding studies of educational games.</span></span><br /><br /><span style="font-family: Arial;">Although traditional video games have been linked to obesity and physical inactivity, the newer generation of exergames, like the Wii, have the potential to reverse the trend.&nbsp; But how much energy is actually expended playing?&nbsp; A <a href="http://archpedi.ama-assn.org/cgi/content/abstract/164/7/664?maxtoshow=&amp;hits=10&amp;RESULTFORMAT=&amp;fulltext=exergaming&amp;searchid=1&amp;FIRSTINDEX=0&amp;resourcetype=HWCIT">meta-analysis</a> of 18 pediatric studies&nbsp;found that on average, gamers achieve 3.3 "METS," or metabolic equivalents, of activity, which is the equivalent of brisk walking or skipping.&nbsp; A 60-pound kid would have to play for 90 minutes to burn off one single-serving bag of Doritos (150 calories).&nbsp; Dance Dance Revolution uses the most energy, followed by Wii Boxing, Wii Tennis, and Wii Bowling.&nbsp; Only in the virtual world could bowlers be considered reasonably fit.&nbsp; Unfortunately, video games did not reduce body mass index.</span><br /><br /><span style="font-family: Arial;">Traditional video games do seem to improve visuospatial skills.&nbsp; One trial in 10-year-founds found that playing the game <a href="http://www.sciencedirect.com/science/article/pii/0193397394900043">Marble Madness improved tests of spatial skills</a> compared to those who played computer word games.&nbsp; The benefits were greater in girls, who have lower spatial skills at baseline.&nbsp; Another randomized&nbsp;study found that undergrads who played a total of 6 hours of <a href="http://www.sciencedirect.com/science/article/pii/0193397394900051">Tetris improved in tests in mental rotation and spatial visualization</a>, compared to no improvement in those who were assigned to no video games.&nbsp; Habitual video game players also <a href="http://www.ncbi.nlm.nih.gov/pubmed">test higher in measures of visual attention</a>.&nbsp; They're better at&nbsp;identifying multiple targets&nbsp;and ignoring&nbsp;visual distractions, and they have <a href="http://www.ncbi.nlm.nih.gov.laneproxy.stanford.edu/pubmed/21248123">faster reaction times</a>.&nbsp;In other words, playing video games makes you better at....playing video games.</span><br /><br /><span style="font-family: Arial;">So can these skills be translated into something marketable?&nbsp; Well, if you're thinking about getting your tubes tied, maybe you should let your teenager take a crack at it.&nbsp;&nbsp;One <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=teenage%20video%20gamers%20obstetrics">study</a> found that teenaged expert video gamers outperformed obstetric interns on a laparascopic simulator.&nbsp; (Laparoscopy is surgery performed through 1-inch incisions, with camera guidance.)&nbsp; At least 10 other studies have found a positive correlation between surgical skills in doctors-in-training and video game experience.&nbsp; I didn't find this too surprising.&nbsp; I've done a few sigmoidoscopies (i.e., partial colonoscopies), and they're a lot like video games, only smellier.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">And that's about all I found in my research.&nbsp; I have to admit that the evidence to support gaming in kids isn't the strongest.&nbsp; At least there aren't any studies showing that video games cause cancer.</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"></span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;">Yet.</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">*A 24 year-old died after playing video games for 80 hours straight.</span><br /><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">**A woman fell off her sofa while playing Wii Tennis.&nbsp; You can get anything published these days, as long as the mechanism of injury is novel.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-8230778542387453312011-12-29T23:56:00.000-08:002011-12-29T23:56:40.540-08:00Still Smoking? Think of the Children!<span style="font-family: Arial,Helvetica,sans-serif;">How's the second week of winter break going for you?&nbsp; How many times have you screamed at your kids?&nbsp; Fed them Christmas candy for breakfast?&nbsp; Confiscated your toddler's new set of horns, a gift from your relative with a grudge?</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">I've found a surefire way to cheer myself up whenever I feel exhausted and guilty at the end of a Bad Mommy day.&nbsp; No, I don't look through my kids' "You're the best mom in the world!" cards -- you do realize their teachers <i>force </i>them to write that.&nbsp; No, I cope by thinking about other women who are much worse mothers than I am.&nbsp; I'm talking celebrity moms.&nbsp; Moms who are impossibly rich and beautiful but can't be bothered to whip up some Kraft mac n' cheese.&nbsp; Moms like Britney Spears, who not only smokes around her kids, but also allows them to play with her cigarettes and lighter.</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-4Tv0wLahf10/Tv1qRpS8CDI/AAAAAAAAG9g/XwLHB0XRY3I/s1600/BSpears.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/-4Tv0wLahf10/Tv1qRpS8CDI/AAAAAAAAG9g/XwLHB0XRY3I/s320/BSpears.jpg" width="290" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">It's probably not fair of me to pick on poor Britney.&nbsp; If the paparazzi were tailing my family, they'd probably catch my kids setting the dog on fire.&nbsp; And I wouldn't look half as good in that bikini.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">While Brit probably knows about smoking's ill effects on her own health, she may not be fully aware of the dangers of secondhand smoke, including increased risks of sudden infant death syndrome, ear infections, and asthma, not to mention a higher likelihood that her own children will smoke in the future.&nbsp; In fact, <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=survey%20quitlines%20parents%20smoking">half of parents who smoke claim they have never been counseled by a pediatrician to stop</a>.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Keeping your child healthy should be a powerful motivation to quit, but is this protective instinct enough to overcome the addiction?&nbsp; A <a href="http://pediatrics.aappublications.org/content/early/2011/12/21/peds.2010-3209.abstract">meta-analysis</a> published in <i>Pediatrics </i>this week found that programs that counsel parents on the dangers of secondhand smoke do increase the chances of quitting successfully, though the benefit was small: 23% in the intervention groups quit, compared to 18% in the control groups.&nbsp; Interestingly, parents of children over the age of 4 were more likely to quit with counseling, while those of younger children weren't.&nbsp; The authors speculated that despite the increased risk of SIDS, mothers with newborns may be less able to stop smoking during this particularly stressful time.&nbsp; Another possible reason is that as kids get older, parents may be more motivated to model healthy behaviors.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">So for those of you still trying to quit, stick with it.&nbsp; Make a New Year's resolution.&nbsp; Ask your pediatrician to give you a pep talk at your child's next visit, and make an appointment with your own doctor to see if you should be prescribed any medication to help you quit.&nbsp; Don't be surprised if this is the hardest thing you've ever had to do.&nbsp; In fact, the tobacco companies are on to you -- there are <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=cigarette%20advertising%20new%20year%27s">more cigarette ads in January and February</a> than any other month.&nbsp; If you relapse, don't beat yourself up.&nbsp; It takes the average smoker eight tries before she's able to quit for good.&nbsp;&nbsp;</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">If all else fails, just think of Britney.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp;</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com3tag:blogger.com,1999:blog-3130875298893755906.post-55163641584916688652011-12-21T22:44:00.000-08:002011-12-21T23:02:35.850-08:00Meeting Mr. Sa (a.k.a. Frank Pus)<span style="font-family: Arial,Helvetica,sans-serif;">As a working mom, I accept that my toddler is going to be exposed to drool, snot and microscopic fecal contamination from his fellow daycare inmates.&nbsp; But I draw the line at pus.&nbsp; So imagine my dismay when one of my son's caregivers pulled me aside and said, "I get a lot of boils. Would you mind taking a look?"&nbsp; Whereupon she rolled up her shirt, revealing a lovely specimen, which fortunately had already burst and dried up.&nbsp; Most boils and abscesses are caused by <i>Staphylococcus aureus</i>, and in my area, about 60% are methicillin-resistant.</span><br /><br /><span style="font-family: Arial;">MRSA (along with some forms of strep) is commonly described as the "flesh-eating bacteria" in the media.&nbsp; While MRSA can result in serious, life-threatening infections, more often it causes nettlesome skin infections that may require incision and drainage and treatment with specific classes of antibiotics.&nbsp; The classic presentation is that of a "spider bite," <i>sans </i>spider.</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-Xw-t4Hws9fs/TvLTWAQR9qI/AAAAAAAAG9U/e9YmvoSgVFE/s1600/MRSA.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="206" src="http://4.bp.blogspot.com/-Xw-t4Hws9fs/TvLTWAQR9qI/AAAAAAAAG9U/e9YmvoSgVFE/s320/MRSA.jpg" width="320" /></a></div><div style="text-align: center;"><i><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source: Dermatlas.org</span></i></div><br /><span style="font-family: Arial;">It used to be that MRSA was seen primarily in hospitalized patients, but in the past 10 to 15 years, we've seen a meteoric rise in a particular strain in the community.&nbsp; MRSA is contagious, and pediatric outbreaks have been described in daycare centers and on sports teams.</span><br /><br /><span style="font-family: Arial;">So what can you do to protect your child?&nbsp; Unless you plan on raising a bubble boy or girl,&nbsp;MRSA is&nbsp;not entirely preventable.&nbsp; It's best to avoid sharing sweaty sports equipment and towels, which&nbsp;are often colonized.&nbsp; And there is another thing you can do to reduce the risk: Avoid unnecessary antibiotics.&nbsp; Antibiotics wipe out&nbsp;the good bacteria with the bad, allowing resistant strains to flourish.&nbsp; And many conditions frequently treated with antibiotics, such as <a href="http://evidencebasedmommy.blogspot.com/2011/10/ears-lookin-at-you-kid.html">ear infections</a>, tend to resolve on their own anyway.</span><br /><br /><span style="font-family: Arial;">A&nbsp;recently published <a href="http://www.ncbi.nlm.nih.gov/pubmed/21810624">study</a>&nbsp;looked at all the MRSA diagnoses in kids from 400 general practices in the U.K., and compared them to same-age controls.&nbsp; They then looked at the kids' exposure to antibiotics 1 to 6 months prior to the MRSA infection.&nbsp; Children who were infected with MRSA were three times as likely to have received antibiotics during that time period than those who weren't infected.&nbsp; The more antibiotics received, or the stronger the antibiotic (i.e., those with the broadest spectrum of activity), the stronger the association.&nbsp; Of course, it's possible that a child receiving multiple antibiotics is just more prone to infections, and the antibiotics <i>per se</i> are not causing the MRSA.&nbsp; The authors still found a correlation after controlling for baseline diseases, such as diabetes and asthma.&nbsp;</span><br /><br /><span style="font-family: Arial;">Here's another disturbing possibility:&nbsp; some of those kids might have actually picked up the MRSA from the doctors' office.&nbsp; <a href="http://www.ncbi.nlm.nih.gov/pubmed/21292349">Healthcare workers have colonization rates of up to 15%</a>, and you know that <a href="http://www.ncbi.nlm.nih.gov/pubmed/20088678">most of us don't wash our hands</a> after we <a href="http://www.ncbi.nlm.nih.gov/pubmed/16874648">pick our noses</a>.&nbsp; Even worse, one <a href="http://www.ncbi.nlm.nih.gov/pubmed/19145528">study</a> found that a third of stethoscopes in one ER were contaminated by MRSA.&nbsp; Since I work in a hospital, I could hardly blame my daycare if my son had become infected.</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-size: x-small;"><a href="http://2.bp.blogspot.com/-grqEKhk1mmU/TvLMShVgnNI/AAAAAAAAG9I/SfRZ-OoiN2w/s1600/IMGP0006.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-grqEKhk1mmU/TvLMShVgnNI/AAAAAAAAG9I/SfRZ-OoiN2w/s320/IMGP0006.JPG" width="240" /></a></span></div><div style="text-align: center;"><span style="font-family: Arial;"><span style="font-size: x-small;">Bringing home the superbug</span></span></div><br /><span style="font-family: Arial;">I admit I was caught flat-footed by this curbside consult, and I ended up advising my son's caregiver to see her own doctor.&nbsp; I told her a little about decolonization protocols, which involve bathing with antiseptics, taking antibiotics and lacing your nostrils with Bacitracin.&nbsp; Unfortunately, unless you place all your clothes, bedding and pets on a bonfire*, re-colonization is the norm, so these protocols aren't often used.&nbsp; Though I told her she had a bacterial infection, I avoided using the M-word in front of the other parents.&nbsp; I also didn't recommend staying home during her outbreaks, though I did suggest she cover up her boils with gauze.&nbsp; Afterwards I tried to hand off my kid to the other providers as discreetly as possible.&nbsp; This happened many years ago, and I still wonder whether I did the right thing.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">What would you have done?</span><br /><span style="font-family: Arial; font-size: x-small;"><br /></span><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*Kidding!&nbsp; I don't want to be held responsible for any hamster roasts.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com2tag:blogger.com,1999:blog-3130875298893755906.post-89717131072883356722011-12-13T21:35:00.000-08:002011-12-13T21:35:47.751-08:00Cuckoo for Cocoa Puffs?<div class="separator" style="clear: both; font-family: Arial,Helvetica,sans-serif; text-align: center;"><a href="http://3.bp.blogspot.com/-6nWyD7G9yR4/Tub1EwOJMbI/AAAAAAAAG8s/jfBwAgEsTvU/s1600/JellyBellyFactory1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://3.bp.blogspot.com/-6nWyD7G9yR4/Tub1EwOJMbI/AAAAAAAAG8s/jfBwAgEsTvU/s320/JellyBellyFactory1.jpg" width="213px" /></a></div><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"><span style="font-size: x-small;">A visit to Jelly Belly heaven....</span></div><div style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">will I be paying for this later?</span></span></div><div class="separator" style="clear: both; text-align: center;"></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">One of the enduring myths of Christmas (aside from the man with the bag) is that eating all those candy canes will make your kids go bonkers.&nbsp; There are certainly observational studies showing that sugar ingestion leads to inattention and impulsivity.&nbsp; But if you look at only&nbsp;the well-designed,&nbsp;<a href="http://www.ncbi.nlm.nih.gov/pubmed/8747098">double-blind, placebo-controlled studies</a> (there have been at least a dozen), not one has found&nbsp;that sugar has a&nbsp;deleterious effect on behavior in kids, even in those with attention deficit-hyperactivity disorder (ADHD).</span><br /><br /><span style="font-family: Arial;">The definitive <a href="http://www.ncbi.nlm.nih.gov/pubmed/8277950">study</a> was performed in normal preschoolers, as well as 6- to 10-year olds whose parents had identified as being "sugar sensitive."&nbsp; The care involved in the design of this trial was remarkable.&nbsp; A dietician supervised the removal of all the food from the home, except for coffee and alcohol "as long as they were not consumed by the children."&nbsp; The families were then provided with meals for the next 9 weeks.&nbsp; The experimental diets, which rotated every three weeks,&nbsp;included one that used sucrose (sugar) as a sweetener, one that used aspartame (Nutrasweet), and one that used saccharin.&nbsp; The families were not told the hypothesis, or what substitutions were made.&nbsp; In fact, the investigators created sham diets that changed every week,&nbsp;to throw the parents off the scent.&nbsp; One sham diet, for instance,&nbsp;consisted mainly of red and orange foods (although no artificial food coloring or additives were allowed).&nbsp; Every three weeks, children underwent tests of their memory, attention, motor skills, reading and math performance.&nbsp; Interviewers also surveyed parents and teachers about their kids' behavior.</span><br /><br /><span style="font-family: Arial;">The blinding was near perfect; only one parent correctly identified the sequence of diets.&nbsp; Even though&nbsp;48 tests and surveys were conducted per child, almost none found a difference in cognition or behavior among the three diets.&nbsp; The one exception? Children on the sugar diet scored significantly better on the cognition portion of the Pediatric Behavior Scale.&nbsp;&nbsp;I'm tempted to&nbsp;use this as a <i>post hoc</i> justification&nbsp;for letting my kids eat <a href="http://evidencebasedmommy.blogspot.com/2011/12/now-with-more-protein.html">Cap'n Crunch</a>, but it's probably just a chance finding.</span><br /><br /><span style="font-family: Arial;">Nonetheless, some parents continue to insist that sweets make their kids hyper.&nbsp; Once you believe something, you're more likely to see it.&nbsp; In one <a href="http://www.ncbi.nlm.nih.gov/pubmed/7963081">study</a>, thirty-five 5- to 7-year-old boys who were reported to be sensitive to sugar were randomized to two groups.&nbsp; In one group, the mothers were told their sons&nbsp;would receive a sugary drink; in the other group, they were told that they would receive a Nutrasweet drink.&nbsp; They then videotaped the boys playing by themselves and with their mom.&nbsp; The boys also wore an "actometer" on their wrists and ankles as an objective measure of their activity level.</span><br /><br /><span style="font-family: Arial;">Here's the twist:&nbsp; <i>Both groups actually received Nutrasweet.</i>&nbsp; As expected, there was no significant&nbsp;difference in the boys' activity levels by videotape review or actometer readings.&nbsp; But the mothers who <i>thought</i> their sons consumed sugar reported significantly more hyperactivity during the play session than those who knew they were drinking Nutrasweet.&nbsp; The videotape reviewers (who were blinded to the intervention) also found that the mothers who thought their boys drank sugar were more likely to hover around them, yet they scored lower in warmth and friendliness.&nbsp; It was kind of a mean study, if you think about it.&nbsp; First, they lied to the moms, then they slammed them for being more vigilant.</span><br /><br /><span style="font-family: Arial;">So why, despite the plethora of data to the contrary,&nbsp;has the sugar myth persisted?&nbsp; It's possible that something else in the sweets, such as food coloring or caffeine, causes hyperactivity.&nbsp; And think about it: When do we do let our kids&nbsp;consume copious amounts of sugar?&nbsp; On birthdays, Halloween, and Christmas -- all recipes for going a little nuts.</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-34259717179010825492011-12-08T17:11:00.000-08:002011-12-12T14:35:49.765-08:00Now With More Protein!<span style="font-family: Arial,Helvetica,sans-serif;">My kids' favorite cereal is Cap'n Crunch Crunch Berries.&nbsp; Hey, I'm a health-minded mom; I&nbsp; make certain that they get a serving of fruit every morning.&nbsp; Sure, Crunch Berries might not have the same anti-oxidant, cancer-fighting properties of acai berries.&nbsp; (Amazonian natives&nbsp;don't get&nbsp;cancer, so it <i>must</i> be true!)&nbsp; But I sure ain't gonna feed 'em the fruitless stuff.</span><br /><br /><span style="font-family: Arial;">They&nbsp;were rooting around in the pantry for their fix when they came across this old cereal container:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-XXF15a7KD-M/TuFd_W4LHeI/AAAAAAAAG8E/2dxKgSMqBA4/s1600/IMG_0658.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://1.bp.blogspot.com/-XXF15a7KD-M/TuFd_W4LHeI/AAAAAAAAG8E/2dxKgSMqBA4/s320/IMG_0658.JPG" width="213px" /></a></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-lEw_dNpG6lo/TuFgL7kU_kI/AAAAAAAAG8c/yQg79z803G0/s1600/Larvae.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="224px" src="http://4.bp.blogspot.com/-lEw_dNpG6lo/TuFgL7kU_kI/AAAAAAAAG8c/yQg79z803G0/s320/Larvae.jpg" width="320px" /></a></div><br /><span style="font-family: Arial;">I tried to pass off the larvae* as a science experiment/proof of spontaneous generation/Christmas surprise, but my kids would have none of it.&nbsp; I was tempted to call the Captain himself&nbsp;to complain about the inaccurate nutrition labelling, when my husband discovered another little squirmer in a half-opened box of Cinnamon Life.&nbsp; Somehow finding one larva in your cereal is way more disturbing than finding a colony of them.</span><br /><br /><span style="font-family: Arial;">No doubt some of you are more disgusted that I let my kids eat sugary cereal than by the fact that my pantry is an insect zoo.&nbsp; And indeed, you would be in the right.&nbsp; There are no studies examining the larval content of sugary cereals, but there&nbsp;is&nbsp;a study showing that there is (brace yourself) sugar in sugary cereal.&nbsp; </span><br /><br /><span style="font-family: Arial;">The Environmental Working Group released a <a href="http://breakingnews.ewg.org/report/sugar_in_childrens_cereals/">report</a> this week on the sugar content&nbsp;of 84 popular breakfast cereals.&nbsp; Only one in four met the U.S. government's guideline of having less than 26% added sugar by weight.&nbsp; The worst was Kellogg's Honey Smacks, followed closely by Post Golden Crisps (formerly known as Sugar Smacks; there used to be truth in advertising).&nbsp; Cap'n Crunch Crunch Berries came in 9th, with 42% added sugar.&nbsp;&nbsp;A cup&nbsp;has 11 grams of sugar, which is less than a Twinkie but more than two Oreos.&nbsp; You can imagine how upset I was when I read that.&nbsp; I've since reformed my ways, and this is what I now serve my kids in the morning:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-E5bUdqYGk5w/TuFhYygpFuI/AAAAAAAAG8k/NUs_DyroWwY/s1600/Oreos.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="224px" src="http://3.bp.blogspot.com/-E5bUdqYGk5w/TuFhYygpFuI/AAAAAAAAG8k/NUs_DyroWwY/s320/Oreos.jpg" width="320px" /></a></div><div class="separator" style="clear: both; text-align: center;"></div><br /><span style="font-family: Arial;">Chocolate's an anti-oxidant, isn't it?</span><br /><br /><span style="font-family: Arial; font-size: x-small;">*They weren't maggots; maggots eat meat, not fake berries.&nbsp; I have no idea what these larvae would have metamorphed into.&nbsp; (Any entomologists among my readers?)&nbsp; We sprayed them with Raid, squished them, burned them, and scattered their ashes in a lovely forest glen.</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com5tag:blogger.com,1999:blog-3130875298893755906.post-68357990356188016212011-12-06T17:14:00.000-08:002011-12-07T16:01:10.882-08:00Vaccinonomics<span style="font-family: Arial,Helvetica,sans-serif;"><i>Warning:&nbsp; This is one of my wonkier postings.&nbsp; Read on if you'd like to learn more about the supposed science of economic analysis, and how it shapes healthcare policy.</i></span><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-gxm9Bm9I3YQ/Tt3Cc-5TA4I/AAAAAAAAG78/RsVJWc2gPi8/s1600/Diplococcus.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-gxm9Bm9I3YQ/Tt3Cc-5TA4I/AAAAAAAAG78/RsVJWc2gPi8/s1600/Diplococcus.jpg" /></a></div><div style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">How much would you pay to keep this little critter away from your child?</span></span>*</div><br /><span style="font-family: Arial,Helvetica,sans-serif;">I don't have a compelling personal anecdote about meningitis, and I hope I never do.&nbsp;&nbsp;Meningococcus is one of the more common causes of meningitis, and this bug gives even hardened doctors and nurses the heebie-jeebies.&nbsp; For one thing, it&nbsp;spreads by close contact,&nbsp;so members of the same household, or healthcare workers exposed to secretions, must take antibiotics to ward off the same fate.&nbsp; And if you don't die from meningococcus, you could end up with brain damage or multiple limb amputations, since one of the complications is gangrene.</span><br /><br /><span style="font-family: Arial;">So we should be thrilled that there's a vaccine against the most common serotypes that cause disease in adolescents and young adults, who are particularly susceptible to this infection.&nbsp; In the past, a single dose at age 11 or 12 was thought to be protective for 10 years, but recent studies have found that immunity lasts for only five.&nbsp; Last week, the American Academy of Pediatrics issued a <a href="http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;128/6/1213?rss=1">statement</a> recommending a second, booster dose for 16-year-olds.</span><br /><br /><span style="font-family: Arial;">No one argues that adding a booster won't save lives.&nbsp; But is it worth the extra cost, given that meningococcus is still a relatively uncommon disease?&nbsp; Already, kids routinely receive about 30 shots in their childhood -- double the number back in 1980.&nbsp; An <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1110539">editorial</a> in the <i>New England Journal of Medicine</i> argued that "<b>routine adolescent [meningococcal vaccine] does not provide good value for money</b>, largely because of low disease incidence rates and relatively high vaccine cost."</span><br /><br /><span style="font-family: Arial;">You might argue that you can't put a price on a human life, but it turns out you can.&nbsp; Economic analysis is the science of quantifying the cost of healthcare interventions, but as you'll see, there are a lot of smoke and mirrors involved.</span><br /><br /><span style="font-family: Arial;">Let's start off with the basics.&nbsp; One way to measure the cost-effectiveness of a vaccine (or a pill, or seatbelts, or virtually anything) is to express it in <b>dollars per life-year</b> <b>saved</b>.&nbsp; You can see right away that&nbsp;if you had a vaccine that&nbsp;was equally effective across all age groups,&nbsp;it is cheaper to save the life of a baby than the life of a 70-year-old, since you could potentially add 80 years to the baby's life, but only 10 years to Grandpa's.&nbsp; It doesn't mean the baby's life is worth more, only that the vaccine is a bargain when given in infancy.</span><br /><br /><span style="font-family: Arial;">Some illnesses rarely cause death, but there may still be value in preventing them, to avoid complications, hospitalizations or lost productivity.&nbsp; So most economists use the measure of <b>dollars per quality-adjusted life-year, or&nbsp;QALY,&nbsp;saved</b>.&nbsp; How do economists quantify quality?&nbsp; Simple: They ask patients, "If 1 is the value of a perfectly healthy life, and 0 is death, how would you rate having this condition?"&nbsp; Suffering through a cold might be 0.999, while being hooked up to a ventilator and feeding tube might be 0.1.&nbsp; (There are no negative numbers in quality-of-life estimates, though there are probably some fates worse than death.)&nbsp; Already, you can see one of the inherent problems with economic analysis -- quality is an extremely subjective measure.</span><br /><br /><span style="font-family: Arial;">The other methodologic difficulties with this type of research involve knowing what to include in the accounting of costs and benefits, and which estimates to use.&nbsp; Do you analyze the economics from the individual's standpoint, or society's, or the third-party payer's?&nbsp; Each analysis is specific to its country; you can't take an analysis from, say, Singapore, and apply it in the U.K.&nbsp; Although our body of scientific knowledge is constantly changing, economic analyses become rapidly outdated as costs fluctuate.&nbsp; Econ analysis for vaccines is especially tricky, since you have to take herd immunity into account.&nbsp; In other words, the benefits of immunization may extend beyond the immunized.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">One popular myth is that a "cost-effective" intervention saves money.&nbsp; In fact, <b>most modern prevention and treatment measures don't save money at all</b>.&nbsp; The biggest exception?&nbsp; Almost all routine early childhood immunizations, such as the measles and polio vaccines, save money.&nbsp; The same isn't true, though, for the newer vaccines targeting tweens and teens.&nbsp; Why is that?</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">Well, for one thing, adolescents are a hardy group.&nbsp; Their immune system is stronger than infants', and when they do die, it's often a result of their own stupidity -- think of texting while driving.&nbsp; On top of that, there's no loss in productivity when they're sick.&nbsp; (Insert your own lazy teenager joke here.) An adult takes time off from work for illness, and a parent needs to stay home with a sick toddler, but a jobless16-year-old with the flu can fend for himself.&nbsp; And then there's the fact that the newer vaccines aimed towards this age group are a lot more expensive than the older ones.&nbsp; So let's look at the <a href="http://www.ncbi.nlm.nih.gov/pubmed/18174323">cost-effectiveness of some of these vaccines in the U.S.</a>:</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><b>Meningococcus </b>is one of the more expensive, with <b>$88,000 per QALY saved</b>.&nbsp; Giving the double dose ends up being about the same price, since even though you double the cost, you save more lives.</span><br /><br /><span style="font-family: Arial;">Annual <b>influenza vaccine</b> in 12- to 17-year olds is very pricey, at <b>$119,000 per QALY</b>.&nbsp; Compare this to only <a href="https://research.tufts-nemc.org/cear4/SearchingtheCEARegistry/SearchtheCEARegistry.aspx">$11,000 per QALY in 6 to 23-month olds</a>.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><b>Human papillomavirus virus</b> (HPV) wasn't too bad, at <b>$15,000 to $24,000 per QALY</b>, although it's much more expensive to vaccinate boys than girls, since cervical cancer is more common than penile or anal cancer, and reducing HPV in girls should reduce the frequency of screening and treatment of pre-cancerous lesions.</span><br /><br /><b><span style="font-family: Arial;">Hepatitis A r</span></b><span style="font-family: Arial;"><b>anged from cost-saving</b> in college freshmen <b>to $40,000 per QALY</b> in 15-year-olds.&nbsp; (The wide range should clue you in to the fragility of these economic models.) </span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">The cheapest vaccine?&nbsp; <b>Pertussis booster</b>, at the bargain basement price of <b>$6,300 per life-year saved</b>.&nbsp; Outbreaks of pertussis, or whooping cough, have been linked to waning immunity in adolescents and adults, and while whooping cough is not particularly dangerous to older kids, it's very contagious and can kill unimmunized newborns.&nbsp; Much of its cost-effectiveness derives from herd immunity and the fact that pertussis is an older, cheaper vaccine.&nbsp; Middle school students in California are now required to get the pertussis booster.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">Of course, these numbers give the illusion of hardness to a science that's based on the softest of data.&nbsp; And what is the definition of a "cost-effective" intervention anyway?&nbsp; By convention, a maximum limit of <b>$50,000 per QALY saved is considered cost-effective</b>.&nbsp; There's no logical reason why this number appears in the literature.&nbsp; It hasn't budged in the past two decades, despite inflation.&nbsp; And $50,000 may be a year's salary for one family, or the price of a car for another.&nbsp; But that's the figure in the minds of policy makers when they try to decide whether a new treatment should be covered by insurance.</span><br /><br /><span style="font-family: Arial;">Here's another way of looking at the numbers:&nbsp; The <i>NEJM</i> editorial laments that the public-sector cost of immunizing one child until adulthood (not including annual flu vaccines) is about $1,450 for males and $1,800 for females.&nbsp; I was surprised to see that this number was so low.&nbsp; After all, we spend much more than that educating and clothing our children.&nbsp; Heck, $100 a year is less than my caffeine budget.&nbsp; Shouldn't we be spending at least that much to keep our kids healthy?</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*For you microbiologists out there, this is technically gonorrhea -- but it's in the same family of bacteria.&nbsp; Giant Microbes apparently found there's a bigger market for an STD than for meningitis.</span></span><br /><span style="font-family: Arial;"><br /></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com2tag:blogger.com,1999:blog-3130875298893755906.post-41322506776560399202011-11-29T22:48:00.000-08:002011-11-29T23:05:50.138-08:00All I Want for Christmas Is....Everything<span style="font-family: Arial,Helvetica,sans-serif;">My kids wrote their letters to Santa today.&nbsp; There was no pussyfooting, no sucking up.&nbsp; They cut right to the chase.&nbsp; Here's my 8-year-old's letter:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-JSXAN-OCMFA/TtW7n2DJ6lI/AAAAAAAAG7U/4KXH97EvnWY/s1600/JJSantaLetter2011Edited.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="128" src="http://3.bp.blogspot.com/-JSXAN-OCMFA/TtW7n2DJ6lI/AAAAAAAAG7U/4KXH97EvnWY/s400/JJSantaLetter2011Edited.jpg" width="400" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;">And my 6-year-old's:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-iSB_2IMbouU/TtXEpunAtFI/AAAAAAAAG70/KScBkWcdgkU/s1600/SarahSantaLetter2011_Page_1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://1.bp.blogspot.com/-iSB_2IMbouU/TtXEpunAtFI/AAAAAAAAG70/KScBkWcdgkU/s320/SarahSantaLetter2011_Page_1.jpg" width="243" /></a></div><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"></div><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">And my 19-month-old's, courtesy of his older sister:</span><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-8qvwLgr4wEg/TtW79CWUdxI/AAAAAAAAG7k/lm4_fiUGhu8/s1600/JosephSantaLetter2011Edited.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://1.bp.blogspot.com/-8qvwLgr4wEg/TtW79CWUdxI/AAAAAAAAG7k/lm4_fiUGhu8/s320/JosephSantaLetter2011Edited.jpg" width="262" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;">I think they're trying to tell me something.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">It's easy to assign the lion's share of blame for the commercialization of Christmas; all you have to do is reach for the remote.&nbsp; There's no question that T.V. advertising triggers the whiny demands.&nbsp; Every published <a href="http://www.sciencedirect.com/science/article/pii/S0193397303000728">study</a> on this topic has noted a correlation between T.V. viewing frequency and purchase requests for food and toys in children.&nbsp; No surprise here -- why would companies spend billions of dollars producing commercials if they didn't work?&nbsp; </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">My favorite studies were conducted in the U.K., analyzing the content of letters to Father Christmas (Santa, to us Yanks) and surveying&nbsp;children and their parents about their viewing habits.&nbsp;&nbsp;The investigators also&nbsp;reviewed toy commercials on children's&nbsp;networks for the 6 weeks leading up to the holiday season.&nbsp; One of the more remarkable findings was that toy ads ran an average of <i>33 times an hour</i> -- and this figure doesn't even include ads for food or other shows. The first <a href="http://www.tandfonline.com/doi/abs/10.1080/01650250143000481">study</a>, conducted in 3- to 6-year olds (who were allowed to dictate or draw their letters), found that the number of items requested went up with the amount of T.V. viewing.&nbsp; There was no associated increase in the request for advertised brands,&nbsp;probably because the children were too young to recall specific names.&nbsp; The <a href="http://www.ncbi.nlm.nih.gov/pubmed/18091090">study</a> was then repeated in 6- to 8-year-olds, and some interesting trends emerged.&nbsp; For one thing, the kids got greedier, with the average number of demands increasing from 3 to 5 items.&nbsp; (I was relieved to discover my kids are no more spoiled than the average brat.)&nbsp; For another, the more T.V. a kid&nbsp;watched, the more advertised brands he or she would request.&nbsp; Girls were more susceptible to brand-name recognition (with Bratz dolls being the most popular), though peer pressure may also have played a role, as the letters were written in a classroom setting.</span><br /><br /><span style="font-family: Arial;">Dealing&nbsp;with the deluge of requests around Christmas is&nbsp;annoying, but can advertising actually impact the moral development of children?&nbsp; Five <a href="http://www.sciencedirect.com/science/article/pii/S0193397303000728">studies</a> have looked at whether T.V. viewing is associated with materialism.&nbsp; Greed was measured by asking children to agree or disagree with statements such as "Money can buy happiness" or "My dream in life is to be able to own expensive things," or by having them choose between toys or friends.&nbsp; Four out of the five studies found significant correlations between the amount of T.V. watched and materialistic values.</span><br /><br /><span style="font-family: Arial;">So what's the best way to grapple with the gimmes?&nbsp; The "duh" answer is to ban the kiddos from watching any T.V., at least from November onward, but most parents aren't willing to go to such extremes.&nbsp; You could outlaw advertising aimed towards children, which is what Sweden does* -- but we all know that industry would never allow that to happen in the States.</span><br /><br /><span style="font-family: Arial;">Believe it or not,&nbsp; a <a href="http://www.ncbi.nlm.nih.gov/pubmed/11437193">randomized, control trial</a> exists to answer this question.&nbsp; In this study, third- and fourth-graders in one school were randomized to a media reduction program, while kids at another school served as the control.&nbsp; The kids in the intervention group received 18 sermons on reducing T.V., videotape and video game use, after which they were challenged to go media-free for 10 days.&nbsp; Incredibly, two-thirds of the kids succeeded with this challenge.&nbsp; The parents were then given an electronic T.V. time manager that restricted usage to 7 hours a week.&nbsp; Only 40% complied with this portion, possibly because&nbsp;Dad (or, not to be sexist,&nbsp;Mom) wasn't willing to give up his ESPN. The kids and parents were asked at the beginning and end of the study about the number of requests for toys seen on T.V. in the previous week.&nbsp; While there were no differences in toy requests at the beginning of the study, by the end, the kids in the intervention group had reduced their number of demands by 70%.</span><br /><br /><span style="font-family: Arial;">While it's unlikely that schools will implement this intensive curriculum, most parents could aim for the 7 hours a week T.V. budget.&nbsp; I love the idea of installing a T.V. time manager, since kids know that it's useless arguing with a&nbsp;computer. Another strategy is to watch T.V. with your kids and talk to them about the commercials.&nbsp; Over half of 6- to 8-year-olds in the Santa letters study couldn't explain what an advertisement was.&nbsp; <a href="http://www.jstor.org/pss/2488623">Studies</a> have shown that talking to your kids about commercials mitigates their insidious influence.</span><br /><br /><span style="font-family: Arial;">The kids don't know it yet, but maybe Santa will surprise them with a T.V. time manager.&nbsp; That's what happens when you try to shake down the big guy.&nbsp; In the meantime, anyone know where I can buy some fake drool?**</span><br /><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*In fact, in a small substudy, Swedish children requested fewer items in their Father Christmas letters than did children from the U.K.&nbsp;</span></span><br /><span style="font-family: Arial;"><span style="font-size: x-small;">**My daughter's explanation: "It's just like fake vomit -- you can use it to gross people out!"&nbsp; Not sure why JoJo would need any, since he produces copious amounts of the real stuff.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com2tag:blogger.com,1999:blog-3130875298893755906.post-50490044671946938532011-11-22T17:56:00.000-08:002011-11-22T17:56:23.266-08:00Flying the Fussy Skies<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-6cI-KJYHU64/TsiRbYOQxRI/AAAAAAAAG7I/iipOtYGjWhw/s1600/IMGP3118.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="http://2.bp.blogspot.com/-6cI-KJYHU64/TsiRbYOQxRI/AAAAAAAAG7I/iipOtYGjWhw/s320/IMGP3118.JPG" width="320" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">&nbsp;Carseat, check. Breastpump, check. Diaper bag, check.&nbsp;</span></span></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">Big brother, check.&nbsp; Baby...baby??</span></span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Three and a half million U.S. travelers are expected to fly<span style="font-size: small;"> over the Thanksgiving holiday this year; and about 1% of passengers are children under the age of 2.&nbsp; That's a whole lotta caterwauling at 25,000 feet.&nbsp; Few</span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: small;"> things can be as stressful as flying with young children.</span>&nbsp; Here are the answers to some common questions about traveling with kids:</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>Should I pay for an extra ticket, so my child can sit in her carseat?</b>&nbsp; The FAA has long considered a proposal to require carseats for children under two.&nbsp; Thankfully, they haven't mandated this rule, and here's why:&nbsp; a carseat is highly unlikely to save the life of your kid.&nbsp; That's because plane crashes are extremely rare, and of those, 30% aren't survivable.&nbsp; Even extreme turbulence resulting in serious injury is uncommon.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/14557157">analysis</a> found that requiring a carseat for every child under two would save 0.4 lives a year in the U.S.&nbsp; I'm not sure, but I think you need at least 50% of your body to survive!&nbsp; They estimated that the additional cost of saving one life would be $6.4 million <i>per each dollar cost per round trip</i>.&nbsp; With the average price of a domestic ticket being $360, that's $2.3 billion dollars to save one life.&nbsp; Now, my kid may be worth that much, but yours isn't -- and I'm sure you'd say the same to me.&nbsp; Not only that, but some families will be deterred by the cost of the extra ticket and end up driving several hundred miles, which is significantly more dangerous than flying.&nbsp; The study concluded that because of this expected shift in air to land travel, requiring carseats on planes will end up killing more children than it saves.&nbsp; That said, bring the carseat along, just in case you win the lottery and find yourself next to an empty seat.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>How can I prevent ear pain?&nbsp;</b> Ear pain is greatest on ascent and descent, as cabin pressure drops and then increases.&nbsp; The pressure lags behind in the middle ear, leading to an changes in the volume of air in the ear, causing discomfort.&nbsp; If the Eustachian tubes leading to your middle ear are open, pressure equalizes quickly, relieving pain.&nbsp; Children have smaller Eustachian tubes that often clamp down with viral infections and allergies, so they're more susceptible to pain.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Swallowing helps open the Eustachian tubes, so you can try nursing or bottle feeding your baby, or having your older kids chew gum.&nbsp; The decongestant pseudoephedrine has been shown in <a href="http://www.ncbi.nlm.nih.gov/pubmed/8198308">randomized, controlled trials</a> to reduce ear pain in adult air travelers.&nbsp; Unfortunately, a small <a href="http://www.ncbi.nlm.nih.gov/pubmed/10323625">study</a> performed in children under the age of 6 found no reduction in ear pain with ascent or descent.&nbsp;&nbsp;</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">If your kid has a history of ear pain with flying, you could consider giving an over-the-counter analgesic 30 minutes prior to descent, when the pain is worst.&nbsp; There aren't any studies looking specifically at prevention or treatment of barotrauma ("baro" = pressure), but if I had to choose a medicine, I'd go with ibuprofen, which was shown in a <a href="http://www.ncbi.nlm.nih.gov/pubmed/8871138">randomized trial</a> to be more effective than Tylenol in treating the pain of ear infection.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">I saw a blurb in a parenting magazine about "EarPlanes," ear plugs designed for kids to wear on flights.&nbsp; The problem is, there's no evidence that they work.&nbsp; In one <a href="http://www.ncbi.nlm.nih.gov/pubmed/16313146">study</a>, each volunteer was given pressure-equalizing earplugs in one ear, and a placebo earplug in the other.&nbsp; The pressure-equalizing earplugs were useless: 75% experienced ear pain on descent.&nbsp; So save the earplugs for yourself, so you won't have to hear the little tyke yowling.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>Should I slip my kid a mickey?</b>&nbsp; Some of you will no doubt have trouble with the idea of sedating a child for your own comfort.&nbsp; I don't have a moral objection, but I do have an evidence-based one:&nbsp; It doesn't work, at least with any over-the-counter medications.&nbsp; Diphenhydramine, which is Benadryl, is the most studied OTC sedative.&nbsp; Although there are no studies of pediatric in-flight sedation, we can extrapolate from the <a href="http://www.ncbi.nlm.nih.gov/pubmed/16818836">TIRED* study</a>.&nbsp;&nbsp; The exhausted parents of 44 infants with frequent night-time awakenings drugged their progeny with either diphenhydramine or placebo.&nbsp; Almost no child (and by extension, no parent) was reported to have improved sleep by the end of the trial.&nbsp; In addition, Benadryl can cause paradoxical excitation in children -- the last thing you need when they're already giving the passenger in front of them a back massage with their feet.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"> </span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Bottom line:&nbsp; There's not much you can do to make the flight more comfortable for you, your baby or your fellow passengers, other than the time-tested methods of feeding, holding, and walking him up and down the aisles. </span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Here's hoping we aren't on the same flight.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">*<b>T</b>rial of <b>I</b>nfant&nbsp;<b></b></span><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;"><b>Re</b></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">sponse to <b>D</b>iphenhydramine.&nbsp; They kind of had to work for that one. </span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-62239897414542073882011-11-14T23:29:00.000-08:002011-11-17T20:58:31.689-08:00The Picky Eater<span style="font-family: Arial,Helvetica,sans-serif;">My parents are preparing a traditional Thanksgiving dinner for the extended family this year.&nbsp; They're excited to have all their grandkids at the table, but also a bit nervous, as they're venturing far outside their Chinese food comfort zone.&nbsp; I've warned them, though, not to feel hurt if my 6-year-old daughter eats nothing but mashed potatoes.</span><br /><br /><span style="font-family: Arial;">That's right, despite our vibrant heritage of Chinese-American gluttony dating back to the Ching dynasty,&nbsp;my family has&nbsp;been cursed with a picky eater.&nbsp;&nbsp;</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-wQ3tLhOvtc0/TsIMZ1GxHRI/AAAAAAAAG7A/QgfHJzWnZO8/s1600/IMGP0716.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239px" src="http://4.bp.blogspot.com/-wQ3tLhOvtc0/TsIMZ1GxHRI/AAAAAAAAG7A/QgfHJzWnZO8/s320/IMGP0716.JPG" width="320px" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">In-n-Out started her down the road to perdition.</span></span></div><br /><span style="font-family: Arial;">There is no universally accepted definition of what makes a fussy eater, but most parents say they know it when they see it.&nbsp; Nutritionists and psychologists distinguish between two related conditions.&nbsp; Food neophobia is defined as the fear of trying new foods.&nbsp; It's thought to be an evolutionary vestige from our Neanderthal days, when eating something new, particularly a plant, carried a risk of poisoning or illness.&nbsp;Food neophobes will often reject a new food based on sight or odor alone, refusing to even taste it.&nbsp; Neophobia starts at age 2, when the child becomes more mobile and hence, less supervised, and usually ends at around 6 years of age.&nbsp; Picky eating, on the other hand, is the refusal to eat even familiar foods.&nbsp; Picky eaters may be more willing to taste new foods, but will regularly eat only a narrow range of items.&nbsp; Picky eaters gravitate towards carbohydrates and away from vegetables and protein sources.&nbsp; Unlike food neophobia, many picky eaters do not outgrow this tendency.&nbsp; In reality, there is a great deal of overlap between food neophobia and picky eating, and many kids have both.</span><br /><br /><span style="font-family: Arial;">Up to half of parents claim to have a picky eater in their family.&nbsp; The health consequences of picky eating aren't clear.&nbsp; Some studies have shown a lower body mass index in picky eaters, while others have found the opposite.&nbsp; Picky eaters tend to take in fewer nutrients and vitamins, though frank deficiency is rare.&nbsp; And one <a href="http://www.sciencedirect.com/science/article/pii/S0890856709651170">study</a>, which followed children over an average of 11 years, found that picky eaters have more symptoms of anorexia in later adolescence.&nbsp; </span><br /><br /><span style="font-family: Arial;">Scientists aren't even sure of what causes some kids to be picky eaters.&nbsp; <a href="http://www.ncbi.nlm.nih.gov/pubmed/17459432">Twin studies</a> suggest that about two-thirds of picky eating is genetic, rather than environmental.&nbsp; Part of this may be due to a known inherited variation in the ability to taste bitterness in vegetables; those with higher sensitivity may be more likely to avoid veggies.&nbsp; </span><span style="font-family: Arial;">Picky eating may also associated with higher rates of anxiety.&nbsp; </span><span style="font-family: Arial;">Regardless of the underlying cause, meal times can often deteriorate into a battle for control, further exacerbating the pickiness.</span><br /><br /><span style="font-family: Arial; font-size: small;">My daughter Sarah's all-time record was being forced to sit two hours at the dinner table with an unwanted pork chop in her mouth.&nbsp; I finally gave up when she started nodding off.&nbsp; If she was going to choke on something in her sleep, I wanted it to at least be a vegetable.&nbsp; Otherwise, what would the neighbors say?</span><br /><span style="font-family: Arial; font-size: x-small;">&nbsp;</span><span style="font-family: Arial;"> </span><br /><span style="font-family: Arial;">There are studies examining ways to diversify the picky eater's diet.&nbsp; The French, naturally, are on the cutting edge of gastronomical research.*&nbsp; In <a href="http://www.ncbi.nlm.nih.gov/pubmed/18342395">schools in Dijon</a>, half of 9-year-olds were assigned to a weekly 90-minute program to train their tender young palates.&nbsp; The sessions included lectures, cooking workshops, and a field trip to a restaurant (though contrary to stereotype, no wine tastings).&nbsp; The children were surveyed before and after the program, and presented with unusual items, such as leek sprouts and dried anchovies, to taste.&nbsp; Kids enrolled in the program were slightly more likely to sample the offerings.&nbsp; <i>Tant pis</i>, ten months after the program ended, the reduction in food neophobia disappeared and returned to baseline.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">Of course, this study is unlikely to be of much help to those of us in the States, where schools are dealing with budget crunches by dropping frivolous subjects, like long division.&nbsp; So what's a beleaguered parent to do?&nbsp; Here are some tips:</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><b>Munch on a carrot while breastfeeding your baby.&nbsp;</b> (Or better yet, drink a Bloody Mary -- read my <a href="http://evidencebasedmommy.blogspot.com/2011/09/whats-on-tap-mom.html">post</a> on drinking while nursing.)&nbsp; <a href="http://www.ncbi.nlm.nih.gov/pubmed/21872699">Breastfeeding is associated with lower rates of picky eating.</a>&nbsp; It's been well-established that many flavors from a mother's diet are transferred to her breast milk -- which may explain, for instance, why Indian babies have no problems tolerating curry.&nbsp; There's <a href="http://www.ncbi.nlm.nih.gov/pubmed/11389286">weak evidence</a> that consuming carrot juice while nursing increases an infant's acceptance of carrot puree.**&nbsp; Although there are few studies on this topic, there are plenty of other good reasons to nurse.</span><br /><br /><span style="font-family: Arial;"><b>Don't reward your children for eating healthy food.</b>&nbsp; Multiple <a href="http://www.jstor.org/pss/1129954">studies</a> have found that if you reward a child for eating something, she will eat more of it in the short term, but she'll end up disliking and eating less of it in the future -- the thought being, "If Mom has to give me a prize to eat this green bean, it must taste terrible."&nbsp; Even verbal praise for consuming a particular food reduces a child's liking for it.&nbsp;&nbsp;</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><b>Present healthy food as a reward.</b>&nbsp; <a href="http://www.jstor.org/pss/1129474">Rewarding behavior with food increases the desirability of that food.</a>&nbsp; Note that this trick works best with the very young.&nbsp; One researcher who tried the old "eat your dessert, then you may eat your vegetables" <a href="http://www.jstor.org/pss/1129954">ruse</a> was unable to fool a single 4-year-old.</span><br /><br /><span style="font-family: Arial;"><b>Expose your child to the food you want him to eat.&nbsp; Then do it again.&nbsp; And again.&nbsp; And again.</b>&nbsp; In fact, studies show you must present new food to a child a minimum of 10 times for him to finally accept it.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/12781165">randomized trial</a> had parents in the experimental arm present an unpopular vegetable (most often a bell pepper) to their child every day <i>for 14 days</i>.&nbsp; The parents were to encourage their child to taste it, but not to offer any reward for eating it.&nbsp; At the end of the two weeks, kids in the exposure group increased their liking and consumption of the vegetable, compared to no change in the control group.&nbsp; The problem?&nbsp; Many of the parents weren't able to stick it out for the full 14 days, and when they included these kids in the analysis, there was no benefit.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><b>Set a good example for your kids, and eat your veggies.</b>&nbsp; This won't be a surprise to anyone, but several <a href="http://www.ncbi.nlm.nih.gov/pubmed/20840710">studies</a> have found that vegetable consumption in kids closely mirrors that of their parents.&nbsp; Hard to know if this is genetic or environmental, or if there's a cause and effect relationship, but it can't hurt.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">If all else fails, talk to your pediatrician -- preferably someone as non-judgmental as my kids' doctor.&nbsp; I became really concerned when Sarah weighed one pound less at her 4-year-old visit than she did at her 3-year-old one.&nbsp; I bemoaned her tuber-based diet, and asked for suggestions on how I could get her to eat her veggies.&nbsp; Her pediatrician's answer?&nbsp; "Does she eat ketchup with her French fries?&nbsp; Ketchup counts."</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;">Ketchup counts?&nbsp; I've got Thanksgiving covered.</span><br /><span style="font-family: Arial;"><br /></span><br /><span style="font-family: Arial;"><span style="font-size: x-small;">*Public schools in France serve a <a href="http://www.time.com/time/magazine/article/0,9171,1969729,00.html">five-course meal</a> to their students, and no, it's not like in America, where the hors d'oeurves consist primarily of <i>pomme frites</i>.</span></span><br /><br /><span style="font-family: Arial;"><span style="font-size: x-small;">**OK, I&nbsp;realize that&nbsp;you could use the same logic to argue that drinking while nursing could give your baby a taste for Jack Daniels.&nbsp; If you're a breastfeeding mom, just pretend that you never read this footnote.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com5tag:blogger.com,1999:blog-3130875298893755906.post-51310751497074720132011-11-08T23:19:00.000-08:002011-11-09T09:35:45.019-08:00The 5-Second Rule<span style="font-family: Arial,Helvetica,sans-serif;">The other day, JoJo chucked his binky in one of his typical fits of pique.&nbsp; Normally, I follow the 5-second rule, scoop it off the floor and plop it back into his mouth (in order to terminate his fit of pique, of course).&nbsp; This time, though, his aim was true:*</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-BF1SmZ-zMj8/TrolOwbiVeI/AAAAAAAAG64/7KCcudXgIkw/s1600/IMG_0498.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213px" src="http://4.bp.blogspot.com/-BF1SmZ-zMj8/TrolOwbiVeI/AAAAAAAAG64/7KCcudXgIkw/s320/IMG_0498.JPG" width="320px" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">After I plucked it out, Rick suggested running it through the dishwasher, but I knew that I could never give that pacifier to my son without making myself queasy.&nbsp; I threw it out, which meant that JoJo's fit of pique matured into a full-blown tantrum.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Afterwards, I wondered whether my husband's blase attitude about "eau de toilette," or my laissez-faire one about food and binkies hitting the floor, could be justified by any data.&nbsp; My go-to source for health information, Yo Gabba Gabba, seems to contradict my practice:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><iframe allowFullScreen='true' webkitallowfullscreen='true' mozallowfullscreen='true' width='320' height='266' src='https://www.youtube.com/embed/RjFPDUi6Rd4?feature=player_embedded' FRAMEBORDER='0' /></div><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Brobee picks up his Melba toast in a scant 3 seconds, but already it's swarming with tiny, ugly germs.&nbsp; The little monster learns that germs can make him sick, but sadly, not that Melba toast makes for a terribly tasteless snack.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Since YGG didn't include any references in its credits, I did a literature search, and there was indeed a published <a href="http://www.ncbi.nlm.nih.gov/pubmed/17381737">study </a>on the "5-second rule."&nbsp; The microbiologists gleefully painted floor tiles, wood and carpet with <i>Salmonella typhi</i>, the agent of typhoid fever, and then dropped bologna and bread on these surfaces for 5, 30 and 60 seconds.&nbsp; They then made some poor undergraduate eat the samples and observed him for signs of illness.&nbsp; Kidding!&nbsp; They probably couldn't get that experiment past an institutional review board.&nbsp; No, they simply cultured the food afterwards, and found that there was almost no difference in the bacterial contamination rates among the 5-, 30- and 60-second groups.&nbsp; They did find that the colony counts were 10 to 100 times lower on the food that fell on the carpet, so think twice before yelling at your kids for snacking on the expensive Oriental rug.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Of course, most households aren't teeming with typhoid fever.&nbsp; So how dirty are your floors?&nbsp; The vaguely sinister <i>Journal of Hygiene</i> published a <a href="http://www.ncbi.nlm.nih.gov/pubmed/7130703">study</a> of microbial contamination in over 200 homes in Surrey, England.&nbsp; Investigators cultured over 60 sites in the bathroom, kitchen and living room.**&nbsp; Bacteria was found on most surfaces, though the majority of isolates were not pathogens.&nbsp; However, <i>E. coli</i>, which can make you sick if ingested, was found in two-thirds of all households.&nbsp; In general, dry surfaces were rarely contaminated: kitchen and bathroom floors grew <i>E. coli</i> only 3-5% of the time.&nbsp; Toilet water, as you might expect, had <i>E. coli</i> 16% of the time, though at surprisingly low colony counts.&nbsp; The worst area?&nbsp; The kitchen sink, which grew <i>E. coli</i> 19% of the time, with much higher colony counts than toilet water.&nbsp; Dishcloths and drainers were almost as bad.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">So what do I make of this data?&nbsp; I think you can safely say that the 5-second rule has been debunked.&nbsp; Fortunately, it turns out that the average household floor isn't that dirty, which means that the rule can be extended to 60 seconds!&nbsp; I usually throw JoJo's binkies into the kitchen sink to wash, but I've learned that reusing his toilet-tainted pacifier would have been less likely to make him sick.&nbsp;&nbsp;</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">If only I could get past the ick factor.</span><br /><span style="font-size: x-small;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">*True story, but the photo is a re-enactment.&nbsp; I thought about taking a photo when it really happened, but let's just say the bowl was, er, not clean. Like all the other moms I know, I bring my toddler into the bathroom with me so he's not left screaming outside the door.</span><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp; Don't worry, I threw away the second binky too.</span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">**The participants were recruited from "ladies' social clubs," so you could argue that maybe the ladies were scrubbing down the house before the arrival of the research team.&nbsp; The scientists thought ahead and paid repeat, surprise visits and found no significant difference in their culture results.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com1tag:blogger.com,1999:blog-3130875298893755906.post-60150943853456246292011-11-02T12:26:00.000-07:002011-11-05T21:36:49.530-07:00The Kindest Cut, Part 2<span style="font-family: Arial,Helvetica,sans-serif;">Looks like I chose a touchy subject for my last blog post; there appear to be quite a few men mourning the loss of their infantile foreskin.&nbsp; Let me summarize some of the arguments made against my opinion on male circumcision, with my responses:</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">1.&nbsp; <i>You cherry-picked studies showing a benefit for male circumcision.</i>&nbsp; It's true that while numerous observational studies have shown a benefit in terms of UTIs and STDs, there are some studies finding no effect, or even an opposite effect.&nbsp; Non-experimental, observational studies are fundamentally flawed for this reason.&nbsp; That's why it's so important to look at randomized, controlled trials whenever possible.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">2.&nbsp; <i>The risk of UTIs in male infants is low and does not justify circumcision.&nbsp;</i> I totally agree.&nbsp; The reduction in UTIs alone is not large or clinically important enough to advocate for this procedure.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">3.&nbsp; <i>The trials in Africa are flawed because they weren't double-blinded, and they were stopped early.</i>&nbsp; OK, YOU design a study that does sham circumcision in the control group, and try to get that past an ethics committee.&nbsp; Stopping a trial early because of a significant benefit in the treatment group (and offering it to the control group) is the most ethical thing to do in this situation, since HIV is a life-threatening disease.&nbsp; It is true that stopping a study early for this reason tends to overestimate the benefit, and I might be suspicious of the results if they were seen in only one trial, but in fact, the benefits were seen in all three studies, in different parts of Africa.&nbsp; The <a href="http://www.ncbi.nlm.nih.gov/pubmed/19370585">Cochrane Group</a>, which is extremely conservative in its recommendations, concluded, "Research on the effectiveness of male circumcision for preventing HIV acquisition in heterosexual men is complete.&nbsp; No further trials are required to establish this <b>fact</b>."</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">4.&nbsp; <i>The trials in adult heterosexual African men don't apply to infants in the developed world.&nbsp;</i> The majority of HIV infections in the U.S. and worldwide are due to unprotected sex.&nbsp; Sure, the <i>absolute </i>reduction in HIV infection with circumcision will be lower in the U.S. than in some parts of Africa, but <i>relative </i>risk reductions tend to remain constant over various patient populations.&nbsp; I do agree that if you're in a part of the world with extremely low rates of HIV infection (such as Australia -- which has a 0.004% annual risk of infection), routine circumcision may not make economic sense.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">5.&nbsp; <i>Why not promote safe sex instead?&nbsp;</i> I'm not saying circumcision should be done instead of teaching safe sex.&nbsp; HIV prevention needs to be multi-pronged, and must also include education, free condom distribution, low-cost antiviral treatment (which reduces transmission rates) and needle exchanges.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">6.&nbsp;<i> Infants die from circumcision, and parents shouldn't be making this decision for them.</i>&nbsp; Yes, babies will rarely die from circumcision, just as people will rarely die from having IVs inserted into their hands or having a severe allergic reaction to antibiotics (both of which I have seen).&nbsp; But AIDS is still a huge killer, even in developed countries.&nbsp; As for parents who want to let their sons make the decision about circumcision once they come of age, I think that's fine.&nbsp; Just realize that adult male circumcision is a bigger procedure, often involving general anesthesia, and may not be covered by insurance plans when done for purely preventive reasons.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">7.&nbsp; <i>Your story about Dr. Nick operating on your kid sounds fishy.</i>&nbsp; Nope, absolutely true.&nbsp; I got a list of low-cost providers because I gave birth at my own, public county hospital.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">8.&nbsp; <i>You're a terrible mom.&nbsp; </i>OK, I will concede that in the moment that I let Dr. Nick circumcise my son, I was a terrible mom.&nbsp; I'm an imperfect parent, which is why I think a lot of people read my blog.&nbsp; If I had to do it all over again, I would still have my son circumcised, but I'd go with this guy instead:</span><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-MR-B6VUMge8/TrGWF9FVlhI/AAAAAAAAG6w/hKu_E-WDygA/s1600/Mohel.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://4.bp.blogspot.com/-MR-B6VUMge8/TrGWF9FVlhI/AAAAAAAAG6w/hKu_E-WDygA/s1600/Mohel.jpg" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">Extra credit if you can name this Simpsons character*</span></span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">9.&nbsp; <i>The foreskin is a part of normal male anatomy, and removing it is mutilation.</i>&nbsp; It occurred to me that this argument probably should have been #1, as many of you have a philosophical objection to circumcision.&nbsp; You think it's wrong to remove normal foreskin for any reason, and I don't.&nbsp; There's nothing we can say that will change each other's minds on this point.&nbsp; </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">And so we have a parting of the ways.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp;</span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">*It's Krusty the clown's dad, </span></span><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">Rabbi Hyman Krustofski.</span></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com37tag:blogger.com,1999:blog-3130875298893755906.post-56014125929902913532011-11-01T23:07:00.000-07:002011-11-05T21:32:14.506-07:00The Kindest Cut?<span style="font-family: Arial,Helvetica,sans-serif;">When J.J. was born, our hospital gave us a list of outside physicians who performed circumcisions.&nbsp; My husband called every provider on the list and made an appointment with the second cheapest one -- the same process by which he selects a bottle from a restaurant wine list.&nbsp; I knew we were in trouble when we were greeted by none other than....</span><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-B5qV-Dm99p8/TqsL1UHn2uI/AAAAAAAAG5c/wiOf1YOrZWM/s1600/NickRiviera.gif" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://3.bp.blogspot.com/-B5qV-Dm99p8/TqsL1UHn2uI/AAAAAAAAG5c/wiOf1YOrZWM/s1600/NickRiviera.gif" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">"Hi everybody!"</span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Actually, Springfield's Dr. Nick was way more professional than this joker, who was dressed in a hospital gown and dirty sneakers.&nbsp;&nbsp;Without introducing himself or asking if we had any questions, he&nbsp;whipped out his instruments and started operating.&nbsp; Rick fled, leaving me to comfort J.J. with a bottle.&nbsp; In the middle of the procedure, the doctor (at least, I hope it was a doctor) said, "Here, hold this," and he handed me the thingy clamped to my son's penis, as he snipped away.&nbsp; (I'm not a pediatrician or a surgeon, but I assure you that "thingy" is a formal medical term used by internists.)&nbsp; And no, I wasn't wearing gloves, nor had I told this guy that I was a doctor. I fretted for days that J.J. would develop <a href="http://www.google.com/imgres?imgurl=http://journal.nzma.org.nz/journal/121-1275/3090/content05.jpg&amp;imgrefurl=http://journal.nzma.org.nz/journal/121-1275/3090/&amp;usg=__Annp47veY2AgSS7Qiaz7ksaBxH4=&amp;h=431&amp;w=473&amp;sz=59&amp;hl=en&amp;start=41&amp;sig2=yNLmXw3jKMejR4x04A7RRw&amp;zoom=1&amp;tbnid=T0_65x944aRKdM:&amp;tbnh=118&amp;tbnw=129&amp;ei=KSOrTpP0M6OwiQK7tbSiCw&amp;prev=/search%3Fq%3Dfournier%2527s%2Bgangrene%26start%3D21%26hl%3Den%26sa%3DN%26gbv%3D2%26tbm%3Disch&amp;itbs=1">Fournier's gangrene</a>, and that I would be to blame for his future as a eunuch.&nbsp;&nbsp;</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Fortunately, the <a href="http://pediatrics.aappublications.org/content/103/3/686.full">risks of circumcision in a developed country are rare</a> (0.2-0.6%) and minor -- typically bleeding, which usually stops on its own.&nbsp; (We doctors have a saying: "All bleeding stops....eventually."&nbsp; Think about it.)&nbsp; But some would argue that there's no reason to put a baby under the knife when it isn't necessary.&nbsp; And then there are those whack jobs (no pun intended) who blame their unhappy sex life on the loss of their infantile foreskin, not realizing that they can't get a date because they are whack jobs who blame their unhappy sex life on the loss of their infantile foreskin.&nbsp; In fact, observational studies have been all over the map in terms of whether circumcision is linked to sexual dysfunction.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">There are no randomized, controlled trials of circumcision in infants, and there probably never will be.&nbsp; Since there aren't any studies employing sham mohels, we must rely on the results of observational studies to guide us on the risks and benefits of neonatal circumcision, with their imperfect corrections for baseline differences.&nbsp; The procedure is linked not only with certain religions, but also with socioeconomic status, with babies born at higher income levels being more likely to be circumcised -- although Dr. Nick and his like-minded colleagues remain a low-cost option for the uninsured.</span><br /><a href="http://www.blogger.com/goog_2063110666"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></a><br /><span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://pediatrics.aappublications.org/content/103/3/686.full">Circumcision does seem to reduce the risk of urinary tract infections</a> in the first year of life - from 1% to 0.1%.&nbsp; Not a huge absolute benefit for a surgical procedure, though infant UTIs do present a significant healthcare cost burden.&nbsp; My pediatrician friends tell me that kidney ultrasounds are routinely performed in male infants with UTIs, to screen for anatomic abnormalities.&nbsp; They often have to perform suprapubic aspirations (sticking a needle through the skin into the bladder) to obtain a clean sample of urine, which is a low-risk procedure, but not a particularly fun one for baby or parent.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://pediatrics.aappublications.org/content/103/3/686.full">Observational studies</a> have also shown that circumcision is associated with a lower risk of sexually transmitted diseases, including HIV and human papillomavirus, the cause of most cervical, anal and now, <a href="http://evidencebasedmommy.blogspot.com/2011/10/one-more-round-on-hpv.html">oropharyngeal cancers</a>.&nbsp; But here the data get particularly sticky, since uncircumcised males are more likely to come from a lower socioeconomic status, which in turn, is associated with a higher rate of STDs.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Although there aren't any experimental studies of infant circumcision, there have now been <a href="http://www.ncbi.nlm.nih.gov/pubmed/19370585">three large randomized, controlled trials of circumcision in over 10,000 adult men</a>.&nbsp; All of these studies were performed in Africa, with the primary outcome being the subsequent rate of HIV infection.&nbsp; It turns out that the foreskin is replete with special cells that are prone to invasion by the AIDS virus, so removing the foreskin should reduce the rate of HIV infection.&nbsp; And indeed it did, by an impressive 50% over a 2-year period.&nbsp; In fact, all three trials were stopped early, and circumcision was offered to the men in the control groups.&nbsp; The studies also found <a href="http://www.ncbi.nlm.nih.gov/pubmed/19086814">reduced rates of HPV infection in both the circumcised men</a> and their <a href="http://www.ncbi.nlm.nih.gov/pubmed/21216000">female partners</a>.&nbsp;&nbsp;</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Now, a 50% relative reduction is a big deal in parts of the world with high baseline rates of HIV infection.&nbsp; In these African studies, only 56 members had to be trimmed to prevent one infection at 2 years.&nbsp; Of course, if you circumcise a baby, the point it to try to reduce his <i>lifetime </i>risk of infection.&nbsp; The 2004-2005 U.S. data show that the lifetime risk of HIV infection in men is 1.87%.&nbsp; Some of those are acquired from injection drug use or maternal-child transmission, but the vast majority of infections are due to unprotected sex.&nbsp; Circumcision should decrease a child's risk of HIV infection, though the magnitude of benefit in the U.S. and other developed countries is unclear, not to mention the risk reduction in the future partners of these boys.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">As for the drawbacks of circumcision in the African trials, there were but a few.&nbsp; Some of the more pleasant "side effects" of the procedure were <a href="http://www.ncbi.nlm.nih.gov/pubmed/18761593">enhanced sensitivity and sexual satisfaction</a> -- finally, a randomized (if not blinded) trial putting to rest the question of sexual dysfunction.&nbsp; In fact, some of these trials found <a href="http://www.ncbi.nlm.nih.gov/pubmed/19370585">increased rates of unprotected sex and number of sexual contacts</a> in the circumcised groups.&nbsp; The increases were marginal, but remember that they were observed in an experimental setting.&nbsp; Now that the benefits have been well-established, what if men got the mistaken notion that circumcision was completely protective against HIV, blunting the potential benefits?&nbsp;&nbsp;&nbsp; I doubt this will be much of an issue in pediatrics, as I can't imagine any parents encouraging their son to sow his wild oats simply because he had been circumcised.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Whatever the studies show, most parents will probably still base their decisions on cultural and personal reasons.&nbsp; Rick and I had no discussions at all about the benefits and risks of the procedure. I deferred to my husband's wishes, and when it comes to circumcision, that seems to be the rule among the couples we know.&nbsp; In 1999, the <a href="http://pediatrics.aappublications.org/content/103/3/686.full">American Academy of Pediatrics</a> acknowledged the "potential medical benefits," but state that "these data are not sufficient to recommend routine neonatal circumcision."&nbsp; Some have argued that <a href="http://www.ncbi.nlm.nih.gov/pubmed/17473102">the AAP needs to advocate more strongly for circumcision</a>, now that we have proof that it saves lives.&nbsp;&nbsp;</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">As for all you expecting, uncircumcised dads, maybe it's time to start a new family tradition.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">*As a doctor, I know I should always use the correct anatomical term.&nbsp; I fear, though, that too many mentions of the P-word will result in hordes of perverts stumbling on to my blog via their search engines.&nbsp; (A lot of boys looking for "<a href="http://evidencebasedmommy.blogspot.com/2011/08/gardasil-girls-gone-wild.html">Girls Gone Wild</a>" were no doubt disappointed to find themselves instead reading about </span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">cervical intraepithelial neoplasia.)</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com38tag:blogger.com,1999:blog-3130875298893755906.post-56107240996590407222011-11-01T23:03:00.000-07:002011-11-01T23:03:05.947-07:00One More Round on HPV<span style="font-family: Arial,Helvetica,sans-serif;">On previous blog posts, I advocated for mandatory <a href="http://evidencebasedmommy.blogspot.com/2011/08/gardasil-girls-gone-wild.html">HPV immunization&nbsp;in girls</a>, but not necessarily&nbsp;in <a href="http://evidencebasedmommy.blogspot.com/2011/09/protect-girls-vaccinate-boys.html">boys</a>.&nbsp; Well, I've changed my mind.&nbsp; The vaccine should also be mandatory in boys.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">A recent study confirmed what most epidemiologists have suspected for a while -- HPV is fueling the stratospheric, 225% rise in oropharyngeal cancers, involving such structures as the tongue and tonsils.&nbsp; In the past, most of these cancers have been associated with tobacco and alcohol.&nbsp;&nbsp;Rates of&nbsp;oral sex have been increasing, as many regard it as being safer than intercourse*, so the combination of that behavior and decreasing smoking rates means that 70% of oropharyngeal cancers are now due to HPV infection.&nbsp; <a href="http://jco.ascopubs.org/content/early/2011/10/03/JCO.2011.36.4596.abstract">("Human papillomavirus and rising oropharyngeal cancer incidence in the United States.")</a>&nbsp; HPV-positive oropharyngeal cancers can be seen in patients as young as 35 or 40.&nbsp; While they tend to have a better prognosis than those who have tobacco-related cancer, standard treatment includes a toxic brew of radiation, chemotherapy and/or major surgery, including glossectomy (tongue removal).&nbsp; There is no such thing as an oral Pap smear, so oropharyngeal cancer is often diagnosed late.&nbsp; Probably one of the most famous patients is celebrated chef Grant Achatz of the restaurant Alinea, who was diagnosed with advanced tongue cancer in 2007.</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-niM8sVn2g6k/TotJ7hwV3bI/AAAAAAAAGzg/G0VBgABIjrc/s1600/DuckTongue.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" kca="true" src="http://3.bp.blogspot.com/-niM8sVn2g6k/TotJ7hwV3bI/AAAAAAAAGzg/G0VBgABIjrc/s1600/DuckTongue.jpg" /></a></div><span style="font-size: x-small;"></span><br /><div align="center"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">This tongue dish from Alinea came from a duck, not the chef.</span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Fortunately for him and his fans, Achatz&nbsp;managed to avoid a glossectomy, and&nbsp;with aggressive therapy, he is now in remission.&nbsp; <i>Un</i>fortunately, if&nbsp;current trends continue, projections show that the number of HPV-related oropharyngeal cancers will exceed the number of cervical cancers by 2020, and over half will be in men.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">Of course, current trends don't have to continue, not if we make HPV vaccination mandatory in all preteens.&nbsp; Although oropharyngeal cancer has not been a studied endpoint in any of the vaccine trials, one can make an educated guess about the expected efficacy.&nbsp; HPV causes 70% of oropharyngeal cancers, 90 to 95% of which are due to HPV-16.&nbsp; The HPV vaccines protect against HPV-16 with 90 to 98% efficacy in an unexposed population.&nbsp; Using the most conservative numbers, the HPV vaccines should prevent 57% of orophayngeal cancers if given early.&nbsp; </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">So do your family a favor.&nbsp; Vaccinate your kid, and save a tongue.</span><br /><br /><span style="font-family: Arial; font-size: x-small;">*It's not an urban legend.&nbsp; Oral sex is safer than other kinds of sex in terms of HIV infection.&nbsp; One episode of receptive oral sex with an HIV+ partner carries a 0.06% risk of infection, compared to 0.1-0.2% for receptive vaginal and 0.3-3% for receptive anal.&nbsp; And oral sex is widely believed to have a lower rate of pregnancy.</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com7tag:blogger.com,1999:blog-3130875298893755906.post-52294045674748423252011-10-25T08:09:00.000-07:002011-10-25T08:09:30.223-07:00Surviving Fright Night<div class="MsoNormal" style="margin: 0in 0in 0pt;"><div style="text-align: center;"><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-IlItVdPdHUU/To_nzSGSawI/AAAAAAAAGz0/v_nY6sKkDLs/s1600/HalloweenKids_5x6.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-IlItVdPdHUU/To_nzSGSawI/AAAAAAAAGz0/v_nY6sKkDLs/s320/HalloweenKids_5x6.jpg" width="253" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp; <span style="font-size: x-small;">Who's the most likely to get hit by a car?</span></span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Check your children's candy before they eat it.&nbsp; Can they can see through their eye holes?&nbsp; Better yet, don't let them wear a mask at all.&nbsp; Make sure that costume isn't flammable.&nbsp; Now, make sure it isn't inflammable.</span><br /><br /><span style="font-family: Arial;">We get the same advice from&nbsp; so-called experts every year on Halloween safety.&nbsp; How much of it, though, is evidence-based?&nbsp; Let's run through the potential dangers of Fright Night, and see which ones you should really be worried about:</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Tampered treats.</b>&nbsp; FALSE (mostly).&nbsp; I think this one has been thoroughly debunked, but for those of you who have never wasted an afternoon on <a href="http://www.snopes.com/horrors/poison/halloween.asp">Snopes</a>:&nbsp;A criminal justice professor concluded in a 2008 review of <a href="http://dspace.udel.edu:8080/dspace/handle/19716/726">Halloween sadism</a> that no child has ever been killed or seriously injured by a contaminated trick-or-treat sweet.&nbsp; Only 1 child has died of Halloween candy poisoning, and he was poisoned by his own father.&nbsp; </span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /><span style="font-family: Arial,Helvetica,sans-serif;">That’s not to say that sharp objects haven’t found their way into candy bars and apples.&nbsp; There is exactly one published <a href="http://www.ncbi.nlm.nih.gov/pubmed/14531489">case report</a> of an adult whose stomach was perforated by a needle thought to be hidden in a Halloween caramel apple.&nbsp; Most tamperings end up being hoaxes, though, perpetrated by kids who want to freak out their parents.&nbsp; Some hospitals go so far as to offer free x-rays of Halloween treats, but two published studies discovered no cases of tampered treats in over a thousand bags of candy.&nbsp; Alarmingly, the authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/8214832">one study</a> hid a needle in an apple as a quality control measure, and one out of the five hospitals tested missed the needle.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp; </span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Drunken teenagers in costume.&nbsp; </b>TRUE.&nbsp; I always feel like I’m being shaken down when surly, Goth teenagers appear at my door on Halloween night, thrusting empty pillowcases into my face.&nbsp; Assuming the Goth get-up isn’t a costume, I should really be thankful that they’re not wearing disguises.&nbsp; One <a href="http://www.ncbi.nlm.nih.gov/pubmed/8456608">survey of Halloween behavior</a> in college students found that wearing a costume is significantly associated with alcohol use.&nbsp; Not only that, but <a href="http://www.ncbi.nlm.nih.gov/pubmed/20304752">Halloween is one of the hardest drinking times of the year</a> for college freshmen, outstripping even spring break.</span><br /><span style="font-family: Arial,Helvetica,sans-serif;">&nbsp; </span><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Sex offenders lying in wait.&nbsp; </b>FALSE.&nbsp; Many states have laws against registered sex offenders passing out treats on Halloween night.&nbsp; There’s no evidence, though, that molesters use this holiday as an opportunity to prey on kids.&nbsp; One&nbsp;<a href="http://www.ncbi.nlm.nih.gov/pubmed/19581428">analysis of&nbsp;over 67,000 nonfamilial child sex crimes</a> found that there was no increase on Halloween, even before the advent of these restrictive policies. These sickos are just as likely to strike on Arbor Day as they are on Halloween.</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Getting hit by a car.</b>&nbsp; TRUE.&nbsp; The Centers for Disease Control reported in 1997&nbsp;that <a href="http://www.ncbi.nlm.nih.gov/pubmed/9380012">pedestrian deaths quadruple on Halloween night</a>.&nbsp; It’s a good idea to have your kid carry a flashlight or glow stick.&nbsp; Just beware of….</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Glow stick injuries.&nbsp; </b>TRUE (but minor).&nbsp; My husband experienced this firsthand when my daughter’s glow stick exploded in his face.&nbsp; He ran screaming to the sink to rinse out his eyes, which were red and painful for the next eight hours. Witnessing their dad’s chemical burn didn’t traumatize my kids in the least.&nbsp; On the contrary, they were mesmerized by the glowing splatter on the rug, which resembled an alien crime scene.</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;">The number of <a href="http://www.ncbi.nlm.nih.gov/pubmed/19557960">glow product exposures</a> reported to poison control centers has been increasing over the years, and the largest spike always occurs around Halloween.&nbsp; Fortunately, no one has ever been seriously injured, including the twelve misguided individuals who <a href="http://www.ncbi.nlm.nih.gov/pubmed/12197797">swallowed intact glow sticks</a>.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>Sporotrichosis from hay bales.&nbsp; </b>TRUE.&nbsp; Sporotric--what?&nbsp; It’s a rare but ugly fungal skin infection transmitted from contaminated plant material.&nbsp; </span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-EfoBSoMCW7E/TpkHazrtsyI/AAAAAAAAG3o/u-QNNTijwaw/s1600/Sporotrichosis2.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="206" src="http://3.bp.blogspot.com/-EfoBSoMCW7E/TpkHazrtsyI/AAAAAAAAG3o/u-QNNTijwaw/s320/Sporotrichosis2.jpg" width="320" /></a></div><div style="text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <i>Source: Dermatlas.org</i></span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-GdTWpFvJwfo/To3rcm9ZCRI/AAAAAAAAGzk/KB3_GGzZXDU/s1600/Sporotrichosis1.jpg" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><span style="font-family: Arial,Helvetica,sans-serif;">One <a href="http://www.ncbi.nlm.nih.gov/pubmed/9290549">outbreak of sporotrichosis</a> was traced to hay bales from a Halloween haunted house.&nbsp; And you thought it was just the scratchy hay from the wagon ride making your butt itch!</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Pumpkin carving injuries.&nbsp; </b>TRUE – unless you use Pumpkin Masters<sup>TM</sup> tools.&nbsp;&nbsp;&nbsp; While there aren’t any epidemiologic reports related to these injuries, there was a <a href="http://www.ncbi.nlm.nih.gov/pubmed/15193901">controlled study</a> of kitchen knives vs. specially designed pumpkin carving tools, performed on cadavers who raised their hands to volunteer:</span><br /><div class="MsoNormal" style="margin: 0in 0in 0pt;"><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-d5CaGYqMpfo/To_oEjR7oFI/AAAAAAAAGz4/2UFUdM3l7Dc/s1600/PumpkinCarvingTest.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://3.bp.blogspot.com/-d5CaGYqMpfo/To_oEjR7oFI/AAAAAAAAGz4/2UFUdM3l7Dc/s320/PumpkinCarvingTest.jpg" width="297" /></a></div><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;">Kitchen knives caused tendon lacerations in 4 out of the 6 fingers tested, while Pumpkin Masters<sup>TM</sup> caused none.&nbsp; (Pumpkin Kutter<sup>TM </sup>severed one finger tendon, much to the company’s dismay, as it had donated its tools for the study.)</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">Pumpkin seed bezoars.&nbsp; </b>TRUE.&nbsp; A bezoar is a collection of ingested, undigested material that causes gastrointestinal obstruction.&nbsp; Bezoars are most commonly made of hair (usually the patient’s own), but come October, these poor disturbed souls switch to pumpkin seeds.&nbsp; There are multiple case reports of unshelled seeds getting stuck in traffic somewhere along the GI tract, including the rectum.*&nbsp; I'll spare you the photo, but for those of you who get a kick out of that sort of thing, you can purchase the <a href="http://td.rsmjournals.com/content/39/1/54.long">article</a> itself.</span></div><br /><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;"><b style="mso-bidi-font-weight: normal;">The undead.&nbsp; </b>TRUE.&nbsp; You think I’m kidding?&nbsp; Then why would the CDC post <a href="http://emergency.cdc.gov/socialmedia/zombies_blog.asp">guidelines</a> on how to survive a zombie attack? Some of their tips include, “Make a list of local contacts like the police, fire department and local zombie response team.”&nbsp; They also recommend having a first aid kit on hand, though they concede that “you’re a goner if a zombie bites you.”&nbsp; Reassuringly, the CDC has a plan to investigate and contain any outbreak of what they term “Ataxic Neurodegenerative Satiety Deficiency Disorder.”</span><br /><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-oyWl8ae2BU4/TpkKX1HIRiI/AAAAAAAAG3w/OHXvu4hiOfs/s1600/Zombies.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="228" src="http://4.bp.blogspot.com/-oyWl8ae2BU4/TpkKX1HIRiI/AAAAAAAAG3w/OHXvu4hiOfs/s320/Zombies.jpg" width="320" /></a></div><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;">Now if only they could teach us how to handle drunken, costumed teenagers.</span></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><br /></div><div class="MsoNormal" style="margin: 0in 0in 0pt;"><span style="font-family: Arial,Helvetica,sans-serif;">Stay safe, everyone.</span><br /><br /><span style="font-family: Arial; font-size: x-small;">*There are also case reports of rectal bezoars due to watermelon seeds, sunflower seeds, popcorn and prickly pear cactus.&nbsp; No glow stick bezoars, thankfully.</span></div>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com1tag:blogger.com,1999:blog-3130875298893755906.post-78773906538470077582011-10-21T17:01:00.000-07:002011-10-21T21:20:28.995-07:00Mattel, Inkorporated<span style="font-family: Arial;">Parents&nbsp;are up in arms over the latest "Gold Label Collector" Barbie,&nbsp;who sports&nbsp;permanent tattoos and leopard-skin leggings, a la Peg Bundy:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"></div><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-rivjeGHkJik/TqHA1nYznZI/AAAAAAAAG4I/FN5FSK94pNk/s1600/TokidokiBarbie.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" rda="true" src="http://2.bp.blogspot.com/-rivjeGHkJik/TqHA1nYznZI/AAAAAAAAG4I/FN5FSK94pNk/s1600/TokidokiBarbie.jpg" /></a></div><br /><span style="font-family: Arial;">She&nbsp;finally did it.&nbsp; Barbie has out-skanked the Bratz dolls.&nbsp; </span><br /><br /><span style="font-family: Arial;">Barbie has dabbled in body art before, but the tattoos packaged with the 2009 Totally Stylin' model were just temporary heart and rainbow designs.&nbsp; Tattoos are becoming increasingly mainstream, with&nbsp;about 13% of adolescents getting inked.&nbsp; It's a perennial rite of passage for&nbsp;teens&nbsp;to&nbsp;adopt outrageous trends just to piss off their parents.&nbsp; The obvious difference, though, between a tattoo and midriff-baring tops is that one is permanent and the other isn't. (Except in cyberspace.&nbsp; Aren't you glad the Internet didn't exist back when you had a mullet?)&nbsp; Sure, your kid could have a tattoo removal in the future, but it's expensive and not always successful. The health risks of tattoos, particularly hepatitis B and C,&nbsp;are generally well known.&nbsp; Some parents, though, feel that if they let their teenager go to a reputable parlor (an oxymoron, if there ever was one), what harm could there be?</span><br /><br /><span style="font-family: Arial;">Plenty, it turns out.&nbsp; Several studies have shown a strong correlation between adolescent tattoos and high-risk behaviors.&nbsp; The largest was a <a href="http://pediatrics.aappublications.org/content/110/6/1058.full">survey of over 6,000 adolescents</a>.&nbsp; At baseline, tattooed kids were more likely to live in a single-parent household with lower levels of parental education and income.&nbsp; After controlling for these risk factors, tattooed kids still had higher levels of substance use, violent behavior, early sexual involvement and school truancy and failure.&nbsp; Another <a href="http://pediatrics.aappublications.org/content/109/6/1021.full">survey</a> found not only higher rates of drug use, violence and sexual activity in tattooed adolescents but also increased risks of disordered eating and suicidal behavior.</span><br /><br /><span style="font-family: Arial;">Wait a minute, you say, having a tattoo is simply <i>associated</i> with these high-risk behaviors -- surely <i>getting </i>a tattoo doesn't <i>cause</i> them.&nbsp; That may be true, but there are multiple studies showing that having a visible tattoo affects others' perceptions in a negative way.&nbsp; In one <a href="http://www.psycontent.com/content/g256v60840648q50/">study</a>, 286 people were asked to describe the personality characteristics of virtual avatars who were identical, except for the presence or absence of tattoos.&nbsp; Tattooed avatars, especially the female ones,&nbsp;were described as having significantly more sexual partners.&nbsp; Another <a href="http://www.ncbi.nlm.nih.gov/pubmed/18400674">study</a> asked college students, <i>a third of whom had tattoos</i>, to describe the personality characteristics of a photographed female model with a large dragon tattoo, compared to the same model with the tattoo Photoshopped out.&nbsp; The students described the tattooed model as being <i>less</i> intelligent, caring, attractive, fashionable and athletic.&nbsp; (On the flip side, she was deemed to be "more creative.")&nbsp; Interestingly, the results were much less impressive when the experiment was repeated with a model who had a small dolphin tattoo.</span><br /><br /><span style="font-family: Arial;">I've never wanted a tattoo, even as a teenager.&nbsp; But when I was a college freshman, I had my ears double-pierced.&nbsp; My conservative, first-generation immigrant parents made me remove the posts so the holes would close up, since "only bad girls" would mutilate their ears like that.&nbsp; When I tearfully tried to explain that the piercing would in no way make me misbehave, they said, "No, but everyone will <i>think</i> you're a bad girl, and you'll attract only the bad boys" -- precisely the same argument I'm now making about tattoos.&nbsp; Double earlobe piercings are so mainstream now, even passe, that I don't think their argument holds water any more.&nbsp; Maybe the same will be true of tattoos in the next 20 years.&nbsp; But you can rest assured that my kids won't be getting inked as long as they're under my roof.</span><br /><br /><span style="font-family: Arial;">Unless they want to write "Mother."</span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com2tag:blogger.com,1999:blog-3130875298893755906.post-25767432699311347772011-10-18T23:53:00.000-07:002011-10-19T23:00:18.015-07:00The AAP Scolds Us -- Again<span style="font-family: Arial,Helvetica,sans-serif;">The American Academy of Pediatrics released an updated <a href="http://pediatrics.aappublications.org/content/early/2011/10/12/peds.2011-1753.abstract">policy statement</a> this week on media use in children under 2, and no surprise, they continue to "discourage" it.&nbsp; This, despite their acknowledgement that "no longitudinal study has determined the long-term effects of media use" in this age group.&nbsp; (Read my earlier post on the <a href="http://evidencebasedmommy.blogspot.com/2011/09/could-idiot-box-make-your-baby-smarter.html">supposed harms of baby videos</a>.)&nbsp; I read the statement carefully, and it is, shall we say, a quixotic document.&nbsp; Here's one helpful tidbit on how to watch a toddler without resorting to television: "Simply having a young child play with nesting cups on the kitchen floor while a parent prepares dinner is useful playtime."</span><br /><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />The last time I tried that with JoJo, he pulled a bottle of beer out of the minifridge and smashed it on the floor.&nbsp; So even if T.V. is decreasing the number of folds in his brain, at least I don't have to worry about an episode of <i>Yo Gabba Gabba</i> ending in a trip to the E.R.&nbsp; Sometimes I think that the AAP just needs to get off its high horse and live the life of a real parent.</span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><br />Speaking of high horses, some years ago, my 3-year-old son ran up to me as I walked through the front door and gabbled, "Mommy Mommy!&nbsp; Daddy was watching this T.V. show and a man was in bed and the man looked at his hand and his hand was wet and his hand was covered in blood and he looked up and there was a HORSE'S HEAD!"&nbsp; I rounded on Rick, "You let J.J. watch <i>The Godfather</i>?!"&nbsp; He&nbsp; shrugged and said, "I didn't know he was paying attention."</span></div><div style="text-align: left;"><br /></div><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-HCV3DnlR_JQ/Tp5lKmL-9II/AAAAAAAAG4A/gbe7QdeIoHI/s1600/HorsesHead.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://4.bp.blogspot.com/-HCV3DnlR_JQ/Tp5lKmL-9II/AAAAAAAAG4A/gbe7QdeIoHI/s320/HorsesHead.jpg" width="299px" /></a></div><div style="text-align: left;"><br /></div><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"><span style="font-size: x-small;">No more Mafia movies for my kids.</span></div><span style="font-size: x-small;"></span><br /><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"><span style="font-size: x-small;">Just adorable, knitted horses' heads.</span></div><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"></div><div style="text-align: left;"><br /><span style="font-family: Arial,Helvetica,sans-serif;">That, my readers, is an example of background television, and the AAP statement devoted a special section to this form of media exposure.&nbsp; Foreground television, such as <i>Baby Einstein</i>, is designed with children in mind.&nbsp; Background T.V. is not designed for kids, but they might be exposed to it for many more hours than foreground T.V.&nbsp; The question is whether background T.V. affects child development in any way.&nbsp; The AAP highlighted two studies suggesting negative outcomes, so let's take a close look at these.</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;">In one <a href="http://www.ncbi.nlm.nih.gov/pubmed/18717911">study</a>, investigators looked at whether the game show <i>Jeopardy </i>affected the solitary play behavior of 1- to 3- year olds.&nbsp; </span><span style="font-family: Arial,Helvetica,sans-serif;">(I guess the Netflix queue for <i>Godfather </i>was too long.*)&nbsp; </span><span style="font-family: Arial,Helvetica,sans-serif;">As expected, when the T.V. was on, the toddlers didn't pay much attention to it, spending only 5% of their time with their eyes on the screen.&nbsp; Correspondingly, the amount of play decreased by 5% with the T.V. on.&nbsp; The authors made much of the fact that although the quantity of play didn't decrease substantially, play was interrupted more frequently, with play episodes lasting about 30 seconds less with the T.V. on.&nbsp; They also noticed that "focused" play episodes (defined among other things as the child having a "serious facial expression with furrowed brow") were also shorter -- by 5 seconds.</span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;">A similar <a href="http://www.ncbi.nlm.nih.gov/pubmed/19765004">study</a>, performed by the same group, looked at the influence of background T.V. on parent-child interactions.&nbsp; When the T.V. was on, parents interacted less with their kids, and the quality of their interactions suffered, with more absent-minded behaviors, such as grooming, and less imaginative play.&nbsp; Finally, having the T.V. on also resulted in parents responding less to their toddlers' bids for attention.&nbsp; I always knew my kids tune me out when the T.V. is on, but I guess I'm doing the same to them.</span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><br /></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;">So what's the take home message about background T.V. in young children?&nbsp; From a purely anecdotal point of view, I wouldn't recommend watching anything with Al Pacino in it while your kids are still awake.&nbsp; From the evidence-based standpoint, the research is scant but generally shows negative short-term effects of uncertain importance.&nbsp; How much T.V. is too much? Thirty-nine percent of parents say that the T.V. is on "constantly" in their household.&nbsp; What the heck, I'm willing to go out on a limb** and say that's too much.&nbsp; </span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif; font-size: x-small;"><br /></span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">*Although probably not anymore.&nbsp; R.I.P., Quickster.&nbsp; Yours was a short, sad, badly named life</span>.</span></div><div style="text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-size: x-small;">**I was going to write "stick out my neck," but I've already gone overboard with the decapitation allusions.&nbsp; I don't want to beat a dead horse.&nbsp; </span></span></div><div style="text-align: left;"><br /></div>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com2tag:blogger.com,1999:blog-3130875298893755906.post-53557849927698855932011-10-18T00:54:00.000-07:002011-10-18T00:58:35.218-07:00Ears Lookin' at You, Kid!*<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-2YPpH8-psCY/TpzLmxJ_dqI/AAAAAAAAG34/xLsYOXDWZAs/s1600/IMG_5638.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://2.bp.blogspot.com/-2YPpH8-psCY/TpzLmxJ_dqI/AAAAAAAAG34/xLsYOXDWZAs/s320/IMG_5638.JPG" width="213" /></a></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Last week, JoJo spiked a temp to 102.7.&nbsp; Since he was already scheduled for his 18-month visit, I had the pediatrician gave him the once over.&nbsp; She diagnosed him with otitis media, or middle ear infection, but her diagnosis was essentially just an FYI.&nbsp; Since ear infections often get better on their own, the doc recommended antibiotics only if he didn't improve in the next 48 hours.</span><br /><br /><span style="font-family: Arial;">I knew she was right.&nbsp; But dadgammit, I wanted to start those antibiotics so he could get back to daycare ASAP, and I could get a good night's sleep!&nbsp; It's times like these when it's tough to be an Evidence-Based Mommy.</span><br /><br /><span style="font-family: Arial;">Here's the argument against routine antibiotics:&nbsp; Some ear infections are caused by viruses, and as you know, antibiotics don't kill viruses.&nbsp; Even mild bacterial infections self-resolve at times.&nbsp; Antibiotics can shorten the course of illness and prevent rare complications such as bone infection and hearing loss, but at the cost of increasing drug resistance.&nbsp; So what may help a patient on the individual level may hurt patients on a societal level.</span><br /><br /><span style="font-family: Arial;">A recently updated&nbsp;<a href="http://www.ncbi.nlm.nih.gov/pubmed/14973951">meta-analysis</a> of eleven randomized, double-blinded trials of over 2000&nbsp;children with ear infections found only a small benefit with antibiotics: 78% in the placebo groups recovered spontaneously within 2 to 7 days, compared to 84% in the antibiotic groups.&nbsp; There was no difference in serious complications.&nbsp; Those on antibiotics also had a 4% absolute increase in vomiting, diarrhea and rash.&nbsp;&nbsp; So taking the 6% benefit and subtracting the 4% detriment, you get, on balance, a measly 2% absolute benefit from taking antibiotics.&nbsp;A review of four other trials found that there was no difference in starting antibiotics immediately versus waiting 48 hours for spontaneous improvement.&nbsp; So even from the standpoint of an individual child, you could make a strong argument to watch and wait. </span><span style="font-family: Arial;">There were certain subgroups that benefited more from immediate antibiotics: children under 2 who had infections on both sides, or those with pus pouring out of their ears.&nbsp; In general, though,&nbsp;antibiotics were almost a wash.</span><br /><span style="font-family: Arial;"><br />Contrast these results with&nbsp;those of a&nbsp;<a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1007174">study</a> published this year.&nbsp; In&nbsp;this randomized trial of children with ear infections, treatment failed in 45% in the placebo group, compared to 19% in the antibiotic group, with an absolute benefit of 26% - much better than&nbsp;the 4% reported in the past.&nbsp; Not only that, but antibiotics led to resolution of fever within <i>6 hours</i>, as well as fewer days of missed work in parents whose kids were in daycare.&nbsp; Sadly, these benefits still came with a price:&nbsp;a 25% increase in diarrhea in the antibiotic group. So pick your poison: irritable baby or irritable, diaper-changing parent?<br /><br />Still, you might wonder why the results of this trial were so much more impressive than that of previous studies.&nbsp;The 2011 study had very strict criteria for middle ear infection, which included a pneumatic otoscopic exam (basically, blowing air into the canal and looking for decreased movement of the eardrum).&nbsp; Although medical students learn this technique, I can tell you that it's rarely used in the primary care setting.&nbsp; Most of the time, pediatricians are just trying to grab a 1-second peek into a screaming baby's ear, and crying itself pinks up the eardrums by dilating blood vessels.&nbsp; Studies have shown that <a href="http://www.ncbi.nlm.nih.gov/pubmed/17976829">these infections tend to be overdiagnosed</a>, especially when earwax is obstructing the view, so it's no wonder that antibiotics are often of marginal benefit.<br /><br />So what's&nbsp;a parent to do with all this conflicting information?&nbsp; If your kid's doctor wants to prescribe antibiotics for a middle ear infection, ask her two questions: <br /><br />1)&nbsp; Is this a pretty clear-cut diagnosis?&nbsp; <a href="http://www.ncbi.nlm.nih.gov/pubmed/12049821">When doctors are "certain" of their diagnosis, the probability of a "real" otitis media is actually 76%</a> -- which believe it or not, is pretty accurate for a diagnosis based purely on history and physical exam.<br /><br />2)&nbsp; Do you think it's safe to wait 48 hours to see if my child gets better on his own?<br /><br />In JoJo's case, I waited, as his doctor thought it would be safe to observe him off antibiotics.&nbsp; He was better within two days&nbsp; This time at least, it looks like I&nbsp;picked my poison wisely.**<br /><br /><span style="font-size: x-small;">*Sorry, I know this is a groaner of a title.&nbsp; As Fred said to George after his ear was sectum sempra'd off, "Pathetic!&nbsp; With the whole wide world of ear-related humor before you....?"</span></span><br /><span style="font-family: Arial;"><span style="font-size: x-small;"><br />**Which hasn't always been the case.&nbsp; I decided not to give my oldest son the antibiotics prescribed to him for an ear infection.&nbsp; He seemed to improve, but on a routine visit a few weeks later, his pediatrician found he had a persistent infection.&nbsp;&nbsp;When he puzzled aloud over why my son "didn't respond" to the antibiotics, I was forced to come clean.&nbsp; My son was deemed cured after a week's worth of treatment/diarrhea, but I've always wondered if my poor maternal decision-making was to blame for his current, frequent refrains of "But Mom, I didn't hear you!"</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-33720171200273071232011-10-12T18:11:00.000-07:002011-10-12T18:11:55.202-07:00The New Merchants of Death<div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-69dvycB548I/TpU2Dc4fYhI/AAAAAAAAG3I/uEfmccEhbrM/s1600/SarahFloating.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://2.bp.blogspot.com/-69dvycB548I/TpU2Dc4fYhI/AAAAAAAAG3I/uEfmccEhbrM/s320/SarahFloating.jpg" width="213px" /></a></div><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"><span style="font-size: x-small;">Why buy your carcinogens when you can get them for free?</span></div><br /><span style="font-family: Arial,Helvetica,sans-serif;">Imagine a place where a child is allowed to&nbsp;buy cigarettes for herself, with only a permission slip from her parents.&nbsp; In many instances,&nbsp;she may&nbsp;smoke her first pack with her mom -- a&nbsp;popular mother-daughter bonding activity.&nbsp;The tobacco industry is completely unregulated, minimizing the risks and touting the health benefits of cigarettes.&nbsp; A popular T.V. celebrity extols the virtuals of the GTL lifestyle -- Gym, Tobacco, Laundry.</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">Sounds like a scene from a developing country?&nbsp; Substitute "indoor tanning" for "cigarettes," and what I've described takes place in all 50 states in the U.S.&nbsp; </span><span style="font-family: Arial,Helvetica,sans-serif;">The comparison of tanning salons to smoking may sound like hyperbole, but consider the&nbsp;similarities:</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>Indoor tanning causes cancer.&nbsp; </b></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;">A 2007 <a href="http://www.ncbi.nlm.nih.gov/pubmed/17131335">meta-analysis</a> of 19 studies&nbsp;in over 7,000 patients found that indoor tanning is associated with a 15% increased rate of melanoma, the deadliest of all skin cancers.&nbsp; That may not sound like much, but when the analysis looked specifically at indoor tanning in those under 35 years old, there was a 75% increased rate of melanoma.&nbsp; There was also a higher risk of squamous cell carcinoma, which is not as lethal, but more common.</span><br /><br /><span style="font-family: Arial;">Most of these studies were "case-control," meaning they looked at the rates of indoor tanning in those who had been diagnosed with melanoma versus those who hadn't.&nbsp; Sure, you could argue that these findings weren't based on randomized, controlled trials, and that people who go to tanning salons are also more likely to sunbathe (just as smokers are more likely to drink and overeat).&nbsp; But there is also a large body of laboratory evidence that UV radiation, whether natural or artificial, induces skin cell mutations, the first step in carcinogenesis.&nbsp; </span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><b>The tanning industry minimizes risks and promotes questionable health benefits. </b></span><br /><br /><span style="font-family: Arial;">Just as the tobacco companies marketed filters for "safer cigarettes," so the tanning industry pushes the concept of the "safe tan."&nbsp; Many companies claim to use only UVA, which is less likely to cause sunburns than UVB.&nbsp; The problem is that both forms of radiation are carcinogenic.&nbsp; Moreover, one can still get burned in a tanning booth, and there are even case reports of patients requiring treatment in a burn unit following indoor tanning.&nbsp; </span><br /><br /><span style="font-family: Arial;">The other argument for a "controlled" indoor tan is that the increase in melanin protects against burns from natural sunlight.&nbsp;&nbsp;Many people using tanning booths to prep themselves for sunbathing.&nbsp; A tan is indeed protective against a sunburn, with a whopping SPF level of 3.&nbsp; Do they even make sunscreen with that SPF level?&nbsp; Increased use of tanning beds has also been associated with more frequent sunburns, so any so-called protective effect is a myth.</span><br /><br /><span style="font-family: Arial;">One fascinating <a href="http://www.ncbi.nlm.nih.gov/pubmed/20138395">review</a> compared the advertising tactics of the tobacco and tanning industries.&nbsp; Both, for example, use physicians in their ads:</span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"></span><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-family: Arial,Helvetica,sans-serif;"><a href="http://2.bp.blogspot.com/-E0X43XoDem4/TpTE56mLNnI/AAAAAAAAG3A/CepG3M2ietI/s1600/PhysiciansLuckies.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" kca="true" src="http://2.bp.blogspot.com/-E0X43XoDem4/TpTE56mLNnI/AAAAAAAAG3A/CepG3M2ietI/s1600/PhysiciansLuckies.jpg" /></a></span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-rQKI_0ClmC8/TpVBTuUwr5I/AAAAAAAAG3Q/PNhOh27OibM/s1600/TanningAdDoctor.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://3.bp.blogspot.com/-rQKI_0ClmC8/TpVBTuUwr5I/AAAAAAAAG3Q/PNhOh27OibM/s320/TanningAdDoctor.jpg" width="258px" /></a></div><div style="font-family: Arial,Helvetica,sans-serif; text-align: center;"><span style="font-size: x-small;">Text: "After working 16-hour shifts for my residency,</span></div><div style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">I tan because it recharges me for work tomorrow."</span></span></div><br /><div class="separator" style="clear: both; text-align: left;"><span style="font-family: Arial,Helvetica,sans-serif;">More recently, the industry has trumpeted the benefits of tanning on raising vitamin D levels:</span></div><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-7XnZTa-9-Mc/TpVCVEqaqNI/AAAAAAAAG3g/qqEvR9p978Q/s1600/TanningAdVitaminD.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><br /></a></div><div style="text-align: center;"><a href="http://1.bp.blogspot.com/-7XnZTa-9-Mc/TpVCVEqaqNI/AAAAAAAAG3g/qqEvR9p978Q/s1600/TanningAdVitaminD.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="205px" src="http://1.bp.blogspot.com/-7XnZTa-9-Mc/TpVCVEqaqNI/AAAAAAAAG3g/qqEvR9p978Q/s320/TanningAdVitaminD.jpg" width="320px" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;"></span><br /><span style="font-family: Arial,Helvetica,sans-serif;">This claim is wrong on so many levels.&nbsp; Vitamin D deficiency is most frequently seen in the elderly and housebound, not exactly the GTL demographic.&nbsp; You need only 15 to 45 minutes a week of sunlight in order stimulate adequate vitamin D production; a 15 to 30-minute indoor tanning session is equivalent to a day on the beach.&nbsp; Finally, only UVB stimulates vitamin D production.&nbsp; If a tanning salon advertises that it&nbsp;uses only UVA, then the vitamin D argument is patently false.<br /><br /><b><span style="font-family: Arial,Helvetica,sans-serif;">The tanning industry targets youth.</span></b><span style="font-family: Arial;">&nbsp;</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-family: Arial;">A recent <a href="http://www.ncbi.nlm.nih.gov/pubmed/12042536">study</a>&nbsp;showed&nbsp;that 10% of kids ages 12 to 18 have used a tanning bed at least once in the previous year.&nbsp; The figure is highest in teenage girls ages 15 to 18, with a 25% indoor tanning rate.&nbsp; The incidence of melanoma is increasing more rapidly than that of any other cancer in the U.S.&nbsp;&nbsp;Take a wild guess which&nbsp;population is fueling this rise: young females, with a 2.7% annual increase.</span><br /><br /><span style="font-family: Arial;">Everyone in my generation remembers Joe Camel.&nbsp; But even old Joe wouldn't stick his oversized proboscis into a kids' magazine.&nbsp; Not so with tanning salons.&nbsp; A <a href="http://www.ncbi.nlm.nih.gov/pubmed/16618865">survey of high school newspapers</a> in&nbsp;the Denver area&nbsp;showed that almost half carried ads for indoor tanning:</span></span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://4.bp.blogspot.com/-ywB5h8yjunU/TpVBwUuSQrI/AAAAAAAAG3Y/Gyyb9w3Wfrk/s1600/TanningAdProm.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320px" src="http://4.bp.blogspot.com/-ywB5h8yjunU/TpVBwUuSQrI/AAAAAAAAG3Y/Gyyb9w3Wfrk/s320/TanningAdProm.jpg" width="245px" /></a></div><span style="font-family: Arial,Helvetica,sans-serif;"><br /><b><span style="font-family: Arial,Helvetica,sans-serif;">Indoor tanning can be addictive. </span></b><span style="font-family: Arial;">&nbsp;</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-family: Arial;">In a <a href="http://www.ncbi.nlm.nih.gov/pubmed/20404230">survey of 229 college students</a> who used sunbeds, almost 40% met psychiatric criteria for addiction to indoor tanning.&nbsp; When we're exposed to light, our brain produces melanocyte-stimulating hormone (MSH) in order to ramp up production of skin melanin.&nbsp; A byproduct of MSH production is beta-endorphin, a natural&nbsp;opioid.&nbsp; Many users report a sense of relaxation and well-being following a round of indoor tanning, and you can actually block this euphoric response by administering an <a href="http://www.ncbi.nlm.nih.gov.laneproxy.stanford.edu/pubmed?term=tanning%20naloxone">opiate antagonist</a>.</span></span><br /><br /><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-family: Arial;">Daylight saving time is ending soon, and many will be tempted to catch their rays indoors.&nbsp; This week, California became the only state in which minors will not be allowed to indoor tan (starting in </span></span><span style="font-family: Arial,Helvetica,sans-serif;"><span style="font-family: Arial;">2012), even with parental permission.&nbsp; For those of you in the remaining 49, ask yourself: Would I buy cigarettes for my teenager?&nbsp; If the answer is no, then you know what to do with that tanning permission slip.</span></span>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com0tag:blogger.com,1999:blog-3130875298893755906.post-1008593955482938962011-10-10T12:00:00.000-07:002011-10-10T12:00:49.095-07:00Banishing the Boo-Boos<span style="font-family: Arial,Helvetica,sans-serif;">When J.J. was four, he had a psychotic break at the doctor's office when they tried to give him his shots.&nbsp; It took&nbsp;four adults to hold him down, and for years afterward, at every visit the nurse would chirp, "Oh, here's the strong one again!" Now that flu season is approaching, trypanophobia* is setting in again.</span><br /><br /><span style="font-family: Arial;">Then I saw a blurb in a parenting magazine about Buzzy, a vibrating ice pack used to reduce the pain of needlesticks:</span><br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-bNElI6nT0SU/To98BhNtLZI/AAAAAAAAGzs/C3RYjEdKtv0/s1600/KidBuzzy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="293px" kca="true" src="http://1.bp.blogspot.com/-bNElI6nT0SU/To98BhNtLZI/AAAAAAAAGzs/C3RYjEdKtv0/s320/KidBuzzy.jpg" width="320px" /></a></div><div style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Arial,Helvetica,sans-serif;">"Getting shots is fun with Buzzy!"</span></span><br /><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial;">There have been two small, randomized <a href="http://www.ncbi.nlm.nih.gov/pubmed/19920721">studies on Buzzy</a> showing positive results, the first performed on adults using a crude but charming prototype:</span></div><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-PzNMyIvPEcw/To_pcetiCJI/AAAAAAAAGz8/_MQfIqzaQpw/s1600/BuzzyPrototype.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="262" src="http://3.bp.blogspot.com/-PzNMyIvPEcw/To_pcetiCJI/AAAAAAAAGz8/_MQfIqzaQpw/s320/BuzzyPrototype.jpg" width="320" /></a></div><br /><span style="font-family: Arial;">Buzzy reduced the pain of IV insertion by a modest&nbsp;1 point on a 10-point scale.&nbsp; I&nbsp;wanted to try it on my own kids until I saw the $35 price tag.&nbsp; For that amount, I could buy them a bottle of whisky and bullet to bite on.</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial;">The&nbsp;science behind Buzzy is that applying alternative sensations to the poked arm will keep the nerve fibers occupied, reducing conduction of pain impulses.&nbsp; It's an often used strategy in pain control, though the efficacy varies widely according to the population being studied.&nbsp; <a href="http://www.ncbi.nlm.nih.gov/pubmed/19596729">Another study applied this "vibrating instrument"</a> to the <i>opposite </i>extremity to distract from the pain of immunization:</span></div><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="http://2.bp.blogspot.com/-4dNFvT2GdHU/TpFA8ZcxoTI/AAAAAAAAG0A/qw1mZHCwmR0/s1600/Vibrator.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="93" src="http://2.bp.blogspot.com/-4dNFvT2GdHU/TpFA8ZcxoTI/AAAAAAAAG0A/qw1mZHCwmR0/s320/Vibrator.jpg" width="320" /></a></div><br /></div><div style="text-align: left;"><span style="font-family: Arial;">Combined with other measures, this contraption reduced pain in young children.&nbsp; So go ahead, moms, feel free to bring your "personal handheld massagers" to the doctor's office!</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial;">You might wonder how researchers measure pain.&nbsp; Pain is difficult to study, and even more so in children.&nbsp; Pain scales using happy and sad faces can be used in older kids and their parents, but you have to get creative in infants and toddlers.&nbsp; Scientists can measure duration of crying, heart rate and oxygen levels.&nbsp; (You know that prolonged silence before a baby launches into The Serious Wail?&nbsp; Well, he's holding his breath, and his oxygen levels are dropping.)&nbsp; My personal favorite is the Neonatal Facial Coding System, which looks at 9 facial features to assess if an infant is in pain:</span></div><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-fZNvpWtYshQ/TpFFCqRZN0I/AAAAAAAAG0E/NRPRIYrgBNo/s1600/NeonatalFacialPain.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="http://1.bp.blogspot.com/-fZNvpWtYshQ/TpFFCqRZN0I/AAAAAAAAG0E/NRPRIYrgBNo/s1600/NeonatalFacialPain.gif" /></a></div><br /></div><div style="text-align: left;"><span style="font-family: Arial;">Though it's probably sensitive, I have reasons to doubt its specificity.&nbsp; Here's JoJo after getting doused with a hose:</span></div><div style="text-align: left;"><div class="separator" style="clear: both; text-align: center;"><a href="http://1.bp.blogspot.com/-Bhk6-w8V0OQ/To_nTuAGHRI/AAAAAAAAGzw/IZT0EYYvups/s1600/JoJoCrying.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="http://1.bp.blogspot.com/-Bhk6-w8V0OQ/To_nTuAGHRI/AAAAAAAAGzw/IZT0EYYvups/s320/JoJoCrying.jpg" width="240" /></a></div><br /></div><div style="text-align: left;"><span style="font-family: Arial;">His score is a full 9, but he's not in pain -- only cold, wet and humiliated.</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial;">There are hundreds of randomized, controlled trials looking at ways to reduce needlestick pain.&nbsp; The best validated is <a href="http://www.ncbi.nlm.nih.gov/pubmed/20091512">sugar water in infants</a>, with at least 44 studies enrolling nearly 4000 babies.&nbsp; No one knows for sure why this works.&nbsp; It's not due to sucking, as sugar water is superior to breastmilk, formula or water, and it doesn't even have to be given during the shot.&nbsp; Two milliliters given right before the needle is effective.&nbsp; One theory is that the sweet taste results in a release of endogenous opioids, the same mechanism by which chocolate is thought to work.&nbsp; But when one group of <a href="http://www.ncbi.nlm.nih.gov/pubmed/15805377">doctors gave Narcan</a>, the heroin antidote, to babies receiving sugar water, they still cried less than babies who didn't get the sugar.&nbsp; Anecdotally, sweet solutions are amazing. I gave J.J. a juice bottle throughout his circumcision, and he didn't make a peep.&nbsp;(That's right, I assisted in his back-alley circumcision -- but that's a subject for another blog post.)</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial;">The data&nbsp;on sweet solutions are more mixed in children over the age of 1.&nbsp; Browsing through the abstracts on Pubmed, here are some of the strategies that have generally been shown to reduce needle pain, based on randomized, controlled trials:**</span></div><ul style="text-align: left;"><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/11808908"><span style="font-family: Arial;">Topical anesthetic creams</span></a></li><li><span style="font-family: Arial;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/16781075">Television</a> (specifically, the mind-numbing <i>Teletubbies</i>)</span></li><li><span style="font-family: Arial;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18836092">Distractions</a>, such as soap bubbles and toys&nbsp;</span></li><li><span style="font-family: Arial;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/17686797">Rapid injection</a> (instead of slow) </span></li></ul><div style="text-align: left;"><span style="font-family: Arial;"><span style="font-family: Arial,Helvetica,sans-serif;">Others have shown more mixed results:</span> </span></div></div><div style="text-align: center;"><ul style="text-align: left;"></ul><ul style="text-align: left;"><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/8594118"><span style="font-family: Arial;">Topical cold sprays</span></a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/19497458"><span style="font-family: Arial;">The Shotblocker</span></a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/10085835"><span style="font-family: Arial;">Simultaneous instead of sequential shots</span></a></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/10531890"><span style="font-family: Arial;">Music</span></a></li><li><span style="font-family: Arial;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/19596729">Verbal suggestions of less pain</a> (<i>i.e.</i>, lying to your kid)</span></li></ul><div style="text-align: left;"><span style="font-family: Arial;">And these are the useless ones:</span><br /><ul><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/18971084"><span style="font-family: Arial;">Cartoon stickers</span></a> <span style="font-family: Arial;">&nbsp;</span></li><li><a href="http://www.ncbi.nlm.nih.gov/pubmed/20064862"><span style="font-family: Arial;">Coughing while getting a shot </span></a></li></ul><ul></ul></div><div style="text-align: left;"><span style="font-family: Arial;">Finally, have you ever considered leaving the room while your child is being poked?&nbsp; My husband does it all the time, since he&nbsp;gets faint&nbsp;at the sight of a needle.&nbsp;One <a href="http://www.ncbi.nlm.nih.gov/pubmed/2795401">randomized, controlled trial of parental presence vs. absence</a> found that having a parent in the room during immunization increases the level of "behavioral distress,"&nbsp;particularly crying, in kids 4 and over.&nbsp; There was no difference between the two groups in the average heart rate, suggesting there was no true difference in their levels of acute pain.&nbsp; Despite the subjective signs of increased distress, when asked afterwards whether they would want their parent with them during future shots, 86% of the kids said that they would.&nbsp; I love that there's proof that kids play to their audience, and yes, I admit, it does make me feel needed.</span></div><div style="text-align: left;"><br /></div><div style="text-align: left;"><span style="font-family: Arial; font-size: x-small;">*Fear of needles</span></div><div style="text-align: left;"><span style="font-family: Arial; font-size: x-small;">**Unfortunately, all of these RCTs are small and prone to publication bias (<i>i.e</i>., a small positive study is more likely to be published than a small negative one).&nbsp; They are also plagued by lack of blinding, and placebos reduce pain an average of 30-40%.&nbsp; You could argue, though, that since most of these interventions aren't harmful, you might as well use them for their placebo effect.</span></div></div>EBMMommyhttp://www.blogger.com/profile/07223238024256847617noreply@blogger.com6